When a medication is missed or held, the facility's own policy required staff to notify the physician immediately.
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The pharmacy the facility contracts with is in Kansas City.
On September 11, the day inspectors visited Integrity HC of Herrin, a staff member walked by the resident at 11:36 a.m.
Inspectors documented that the elevator, which should have served as a security checkpoint, was not operating with its safety system intact.
Sixteen residents were affected.
The resident, identified in inspection records as Resident A, had ADHD and a colostomy that physician orders required staff to manage every shift.
Inspectors pulled the facility's Omnicell inventory log for that same day.
The resident, identified in inspection records as R2, had been prescribed hydrocodone-acetaminophen 10/325mg for pain.
The complaint that triggered a September 12 inspection centered on a nursing assistant identified in inspection records as NA-P.
The incident happened on August 30, 2025.
The staffing coordinator described both dismissals to inspectors during a September 2025 complaint investigation.
Inspectors were watching when the nurse, identified in the report as V13, prepared noon medications.