Axiom Healthcare West Frankfort: Wrong Eye Vitamin Given - IL
The resident, identified in inspection records only as R5, had a physician's order for PreserVision, an eye supplement. At some point, the pharmacy stopped sending it. The facility started giving her Ocuvite instead. Nobody called the doctor to change the order. Nobody got a new prescription. The medical record kept showing PreserVision, and staff kept signing off that they had administered it.
They hadn't.
When inspectors asked the charge nurse, identified as V2, how long R5 had been receiving Ocuvite instead of her prescribed PreserVision, V2 said she didn't know. When asked whether the physician order still said PreserVision and whether staff had been signing that they gave PreserVision when they actually gave Ocuvite, V2 said she didn't know that either.
V2 was not in the building on August 19 when inspectors arrived.
The assistant director of nursing, V14, said she became aware on August 8 that R5 was getting Ocuvite instead of PreserVision. That was eleven days before the inspection. She said she thought the pharmacy had stopped sending PreserVision because R5 had reached her maximum allowed amount, though she wasn't sure. She did not say whether anyone had contacted the prescribing physician in those eleven days. The inspection record does not indicate anyone had.
The pharmacist, V15, filled in the timeline. PreserVision was last dispensed to the facility on April 28, 2025, a 30-day supply. The pharmacy sent nothing after that because there were no refills on file. If the facility faxed over a new prescription, V15 said, the pharmacy would fill it.
Nobody had faxed anything.
PreserVision and Ocuvite are not interchangeable. The pharmacist said the two products have different formulas, with different concentrations of vitamins and minerals. A physician ordered one. The resident received the other, for a period no staff member could specify, while records indicated she was getting what her doctor prescribed.
The gap between April 28 and August 19 is nearly four months.
CMS rated the violation at the level of minimal harm or potential for actual harm. Whether the substitution affected R5's condition, the inspection report does not say. What it does say is that R5 herself was the one who told the assistant director of nursing on August 8 that something was wrong. Not a nurse. Not a pharmacist review. The resident noticed.
By the time inspectors walked in eleven days later, the prescription still had not been corrected.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Axiom Healthcare of West Frankfort from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
AXIOM HEALTHCARE OF WEST FRANKFORT in WEST FRANKFORT, IL was cited for violations during a health inspection on August 19, 2025.
The resident, identified in inspection records only as R5, had a physician's order for PreserVision, an eye supplement.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.