Resident #3 at Accura Healthcare of Cresco was supposed to receive artificial tears solution four times daily in both eyes for dry eyes. Instead, he missed 55 doses between September 10 and September 24, 2025, according to federal inspection records.
The 67-year-old resident had moderately impaired cognition, scoring just 8 out of 15 on a mental status assessment. His medical conditions included diabetes, dementia, and hemiplegia, which causes paralysis or weakness on one side of the body.
His medication administration record showed a clear pattern: day after day of missed doses with no explanation documented in his medical file.
When federal inspectors asked the Director of Nursing about the gap in treatment, she acknowledged the facility should have contacted the resident's physician. "She would have expected the doctor to be notified of medications not received," the inspection report stated.
But nobody made that call.
The MDS Coordinator explained during an October 8 interview that the facility had run out of stock on September 30. The artificial tears were on back order with their distributor, she said, and should have been ordered through the pharmacy instead.
The facility's own medication policy requires nurses to report supply deficiencies to the director of nursing when medications aren't available. Yet the policy provides no guidance on what to do next when a resident's prescribed medication runs out.
The Director of Nursing told inspectors in an email that staff "didn't do progress notes on phone calls to the pharmacy." No documentation exists showing anyone contacted the resident's doctor during the 14-day period without medication.
The breakdown continued until September 24, when a nurse finally called the facility's pharmacy twice in one morning. The first call came at 9:18 AM, followed by another at 9:58 AM. During both calls, the nurse requested artificial tears and mentioned the facility could no longer get house stock supplies.
The pharmacy's Executive Director confirmed receiving those calls and sending the eye drops the same day. A Licensed Practical Nurse received the medication at 9:10 PM on September 24.
By then, Resident #3 had gone without his prescribed eye treatment for exactly two weeks.
The resident's medical record contained no notes explaining the medication gap to his family or documenting any adverse effects from missing the artificial tears. Federal inspectors found no evidence that staff monitored his condition more closely during the period without medication.
Artificial tears are commonly prescribed for dry eye conditions that can worsen without regular treatment. For elderly residents with multiple medical conditions, consistent medication administration becomes critical to preventing complications.
The facility reported a census of 24 residents during the inspection period. Federal investigators reviewed medication records for three residents and found the administration failure affected one of them.
Accura Healthcare of Cresco's medication management policy was last updated in October 2022. While it requires nurses to report supply shortages to supervisors, it lacks specific instructions for contacting prescribing physicians when medications become unavailable.
The inspection occurred on October 9, 2025, following a complaint. Federal regulators classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The facility's failure to maintain adequate medication supplies and notify physicians about treatment gaps represents a breakdown in basic pharmaceutical services that nursing homes are required to provide under federal regulations.
For Resident #3, the two-week period without eye medication meant 55 missed doses of a treatment his doctor determined necessary for his condition. The gap occurred without his physician's knowledge and without documented consideration of alternative treatments or increased monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Cresco from 2025-10-09 including all violations, facility responses, and corrective action plans.