Inspection·July 11, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure resident's prescribed medication was available for one (R1) of three residents reviewed for medication administration in a sample of three. Findings include: The facility's Medication Administration policy, revised 11/18/17, documents Procedure: 21. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Like medications are not to be Borrowed from one resident to another. R1's current Physician Order Sheet/POS documents an order for Zolpidem Tartrate Oral Tablet 10mg (milligrams) give one tablet by mouth at bedtime related to insomnia. R1's current Care Plan documents a focus of (R1) is on sedative/hypnotic therapy related to insomnia, with interventions including but not limited to Administer Sedative/Hypnotic medications as ordered by physician. On 7/9/24, at 12:36pm, R1 sat in his room and stated he did not receive his Ambien (Zolpidem) two or three times in June due to an ordering issue. R1 said I did not sleep well without it and was up in the middle of the night. I have an anxiety issue and am very regimented. They have no system in place to order meds. R1's Medication Administration Record/MAR, dated June 2024, was signed by V8 Licensed Practical Nurse/LPN and documents R1 did not receive Zolpidem on 6/9/24 and 6/10/24 due to the drug being unavailable. R1's Progress Notes, dated 6/9/24 and 6/10/24, document R1's medication (Zolpidem) was on order. On 7/11/24, at 10:44am, V8 LPN stated I believe it was a weekend when (R1) didn't get his Ambien. It was not available .At the time I was not aware of the narcotic emergency box only the stock med emergency box. On 7/11/24, at 1:30pm, V4 LPN showed this writer the facility's back up Emergency kit in the med room. This kit contained Zolpidem Tartrate (Ambien) 5mg tabs Quantity of 6. V4 confirmed that if a resident was out of Ambien, it could be taken from the kit by calling pharmacy for the code to open it. (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: 145239 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 145239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614 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)