The September 30 federal inspection found two residents missed multiple doses of prescribed oxycodone when the facility ran out of medication. One resident missed six doses over two days, while another missed three doses during a separate incident.
The first resident, identified as R9, takes oxycodone for phantom pain in an amputated right leg and a wound infection in her left leg. She told inspectors on September 17 that she ran out of pain medication and went three days without it.
"I don't know why I ran out either they didn't reorder it, or pharmacy didn't deliver it," she said.
Medical records show R9 was prescribed 5 mg of oxycodone every four hours for pain. Her medication administration record documents she missed the 9 AM, 1 PM, 5 PM and 9 PM doses on September 15, plus the 1 AM and 5 AM doses on September 16.
A licensed practical nurse confirmed the medication shortage. "R9 did run out of her oxycodone. Her prescription had run out, and I think she was changing providers or something," the nurse told inspectors.
The second resident, R2, also experienced medication gaps during what staff described as a pharmacy transition. Records show R2 was prescribed 7.5 mg of oxycodone six times daily for pain but missed three consecutive doses in late August.
Nursing notes from August 29 document staff calling the pharmacy about the medication shortage. "Per pharmacy a quantity of 4 was ordered and 2 sent. Remaining 2 will be sent this morning. New order from MD will be needed," the note states.
R2 told inspectors about a month earlier, "I ran out of my pain medication, but it is better now."
The Director of Nurses confirmed R2 missed three doses of oxycodone during the shortage.
Staff acknowledged the medication supply problems were not isolated incidents. A licensed practical nurse told inspectors, "Sometimes we do run out of pain medication for the residents."
The nurse explained the process when medications run short: "I will call the doctor and get them to send over a prescription to the pharmacy if a new prescription needed to be written. If their order needs to be rewritten, you can't get the medication from the emergency medicine dispensing machine."
The Director of Nurses said the facility was "in the middle of changing pharmacies" during the inspection period. She explained that nurses should call the pharmacy when residents have a week's worth of pills remaining, and if new prescriptions are needed, the pharmacy contacts the doctor.
"If the resident does run out of medication, we have the emergency medicine dispensing machine which the staff can pull medications from. Most narcotics are in there," she said.
However, the emergency system failed to prevent the medication gaps that left residents in pain.
The facility's own medication administration policy requires staff to check for misplaced medications and call the pharmacy when ordered drugs are not available. The policy also states that if medications can be obtained from the contingency box, staff should do so.
When physician orders cannot be followed, the policy mandates timely notification of the physician and documentation in the resident's medical record.
Both residents affected by the medication shortages were documented as cognitively intact, meaning they were fully aware of their pain and the absence of prescribed relief.
The inspection classified the violation as causing actual harm to residents, specifically noting that R9's missed doses "resulted in leaving her in pain."
Federal inspectors found the facility failed to provide physician-prescribed medication for two of seven residents reviewed in their medication sample, representing a significant breakdown in pharmaceutical services during what staff described as a routine pharmacy transition.
The medication shortages occurred despite the facility having policies in place to prevent such gaps and access to emergency medication supplies that should have bridged any temporary shortages.
Both residents' experiences highlight how administrative changes, like switching pharmacies, can directly impact patient care when proper safeguards fail to function as intended.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Alton from 2025-09-30 including all violations, facility responses, and corrective action plans.