F 0755
Level of Harm - Minimal harm
or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview and record review the facility failed to administer medications per
physician's orders for 2 of 3 (R195 and R37) reviewed for medications given on time in a sample of 38.
Residents Affected - Few
Findings include:
1. R195's Physician's Order Sheet (POS), dated 11/2024 documents diagnosis included diabetes with no
diagnosis of rash. 11/21/2024 Tacrolimus topical 0.1% ointment BID (twice a day) for rash on legs.
11/21/2024 Clobetasol topical 0.05% cream BID for rash. 11/21/2024 Metformin 850 milligrams (mg) BID
for diabetes.
R195's Medication Administration Record (MAR), dated 11/2024 documents Tacrolimus 0.1% topical
ointment BID (twice a day) for rash on legs 0 documented as not given on 11/22/2024 through 11/24/2024
8:00 AM dose and 11/22/2024 through 11/26/2024 at 8:00 PM. Clobetasol 0.05% topical cream apply BID
to rash 0 documented as not given at 8:00 PM on 11/22/2024, 11/26/2024 and 11/27/2024. Metformin 850
mg BID 8:00 PM dose 0 documented as not given.
On 12/5/2024 at 10:30 PM V12, R195's wife stated she did not bring any medications including creams or
ointments to the facility and no staff asked her to do that.
2. R37's POS, dated 11/2024 documents no diagnosis listed for anxiety. A physician's order dated,
11/9/2024 Alprazolam 0.25 mg TID (three times a day) for anxiety.
R37's MAR, dated 11/2024 documents an order dated 11/5/2024 Alprazolam 0.25 mg tablet TID for anxiety
8:00 AM, 2:00 PM and 8:00 PM 0 was documented as not given on 11/11/2024 at 8:00 PM dose.
On 12/5/2024 at 10:00 AM V2, DON (Director of Nurses) stated when a resident is admitted to the facility
from the hospital the hospital submits prescriptions for a few days then the facility physician has to send
prescriptions to the facility and if the prescription is sent STAT it usually takes the pharmacy to deliver the
medication within 4-6 hours and when the medication is not send STAT if the medication is ordered before
5:00 PM the medication is usually here by 10:00 PM and when the medication is ordered after 5:00 PM the
medication will be delivered to the facility at 2:00 AM. V2 stated the facility has an emergency backup
medication system but it does not hold controlled medications or creams/lotions and only holds certain
medications which doesn't include Metformin 850 mg. The wound nurse has prescription creams/ointments
on her wound cart but staff wouldn't be able to get a hold of the wound nurse and do not have access to her
wound cart at 8:00 PM. When a medication is not available at the facility staff document a 0 on the
resident's MAR and then write a note as to why
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145102
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Care Center
4315 Memorial Drive
Belleville, IL 62226
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the medication was not given and these missed medications were documented not available from
pharmacy.
On 12/5/2024 at 10:50 AM V2 stated she expects staff to follow the facility's medication administration
policy and to notify nurse supervisor and the resident's provider when a physician prescribed medication is
not available to see if there is an alternate medication to be administered.
On 12/5/2024 at 11:19 AM V1, Administrator showed documentation V14, LPN/RN notified the afterhours
telehealth provider that only prescribed patient 5 Alprazolam which he takes TID. Are you able to call in
more. If not, I can try the afterhours telehealth provider again. Response was RX (physician prescribed
medication) sent. There was no documentation of resident name or any other identifying information on the
paper. V1 stated this was the only documentation of medications that were documented as not available
from pharmacy/documented as not given for the residents and she expected staff to follow the facility's
medication administration policy and to notify the nursing supervisor and the resident's provider when a
medication is not available.
The Facility's Administration of Medication Policy, revised 6/2023 documents purpose: to provide general
guidelines for staff to follow in the administration of medications. Responsibility: it is the responsibility of all
RNs, LPNs, and CMTs to understand and comply with this policy. It is the Nurse Manager's responsibility to
maintain and enforce this policy. Policy: if the medication is unavailable any time, the Nursing Supervisor
should be contacted and may obtain medication from the emergency drug supply or contact the physician
to try to obtain an alternate order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145102
If continuation sheet
Page 2 of 2
