Inspection·January 13, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were administered within one hour of their scheduled administration time for 3 of 6 residents ( R11, R12, and R13) reviewed for medication administration in the sample of 14. The findings include: On 1/12/25 at 11:15 AM, V4 RN (Registered Nurse) was passing morning medications to residents. V4 said she was late with medications because this was her first day working in the facility because she is agency. V4 said there were 6 residents left to receive their scheduled morning medications. R11's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include nonrheumatic aortic valve stenosis, multiple myeloma, pantocytopenia, hyperlipidemia, generalized anxiety disorder, essential hypertension, cerebral infarction, centrilobular emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, spinal stenosis, and urinary tract infection. R11's January 2025 eMAR showed an order for Acyclovir 400 mg twice daily for chemotherapy treatments and Gabapentin 300 mg three times daily for nerve pain. Both of these medications were scheduled to be given at 9:00 AM. On 1/12/25 at 11:15 AM, R11 was still waiting for her 9:00 AM medications to be administered. R12's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include concussion with loss of consciousness, hyperlipidemia, depression, anxiety disorder, obstructive sleep apnea, hypertension, heart failure, and pneumonia. R12's January 2025 eMAR showed an order for colace 100 mg two times daily for constipation. On 1/12/25 at 11:15 AM, R12 was still waiting to receive her 9:00 AM medications to be administered. R13's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of breast, anemia, Type 2 Diabetes, glaucoma, paroxysmal atrial fibrillation, chronic congestive heart failure, thoracoabdominal aortic aneurysm, muscle wasting and atrophy, trochanteric bursitis, chronic kidney disease, wedge compression fracture of fifth lumbar vertebra, and macular degeneration. R13's January 2025 eMAR showed an order for Eliquis 5 mg two times daily for anticoagulant to be given at 9:00 AM, Gabapentin 100 mg two times daily for pain to be given at 9:00 AM, and Tylenol 500 (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: 145667 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 145667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068 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)