Health inspection·September 28, 2023

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 interview and record review, the facility failed to ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 3 of 3 residents (R3, R4, and R5) reviewed for improper nursing care in delay in medication administration in the sample of 5. The findings include: 1. On September 27, 2023, at 10:51 AM, R3 was lying in bed in her room. R3 said she was admitted to the facility on [DATE], around 3:00 PM. R3 said she receives a medication for her restless leg syndrome every night (Pramipexole Dihydrochloride) two different eye drop medications for her glaucoma (Latanoprost and Timolol Maleate), and medication for her depression (Bupropion). R3 said, The medications were not here in the facility the first night I got here, so I did not receive them. I was most worried about the medication I take for my restless leg syndrome because it is so bad that when I don't take the medication, my arms start to shake as well. I did not get the medications that first night because the nurse said they did not get them from the pharmacy in time to give them to me. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, orthopedic aftercare, lumbar region spinal stenosis with neurogenic claudication, post-hemorrhagic anemia, diabetes, heart failure, atrial fibrillation, mild asthma, major depressive disorder, and presence of a cardiac pacemaker. R3's MDS was not completed at the time of this investigation due to her recent admission to the facility. Nursing documentation dated September 21, 2023, shows R3 requires limited assistance by one facility staff member with all ADLs (Activities of Daily Living), including toilet use assistance. R3 has urinary incontinence related to her chronic lumbar spine issues. The EMR shows the following documentation by V14 (RN-Registered Nurse) dated September 21, 2022, related to R3's physician-ordered medications: 6:22 PM - Pramipexole Dihydrochloride oral tablet 0.75 mg. (milligrams). Give 1 tablet by mouth two times a day for Parkinson's Disease - medication not available. 6:22 PM - Bupropion HCl (Hydrochloride) ER (Extended Release) SR (Sustained Release) oral tablet extended release 12-hour 100 mg. Give 1 tablet by mouth two times a day for depression - medication not available. (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 4 Event ID: 146155 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 146155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Place Christian Community 1150 Euclid Avenue Elmhurst, IL 60126 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)