Health inspection·September 17, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received the physician ordered dosage of medication after an order change which applies to 1 of 4 residents (R2) reviewed for pharmacy services in a sample of 4. The finding include: R2's Facility assessment dated [DATE] showed R2 is a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses which includes depression. R2's discontinued Physician Order sheet printed on 9/16/24 showed R2's Doxepin 10 milligrams (mg) order was changed to Doxepin 5 mg on 3/14/24. No other modifications to R2's Doxepin orders were made until 9/12/24. This form showed R2's Doxepin order was changed from 5 mg to 10 mg on 9/12/24. R2's Progress notes dated 3/14/24 showed R2's physician gave a new order to reduce Doxepin to 5 mg. The facility could use the last of the 10 mg doses until the Veterans Affairs (VA) pharmacy could change the medication which could take up to 10 business days. Progress notes dated 3/15/24 showed the pharmacy requested a new order for Doxepin. Doxepin does not come in 5 mg capsules. Doxepin only comes in 3 mg, 6 mg, or 10 mg capsules. Progress Notes dated 4/29/24 showed the VA pharmacy needed a revised script for Doxepin 5 mg to be given in an elixir form. On 9/17/24 at 11:45 AM, V9 Pharmacy Clinical Manager stated Doxepin does not come in a 5 mg dose. It comes in 3 mg and 6 mg tablets and 10 mg, 25 mg and 50 mg capsules. If it needed to be a 5 mg dose it can be made into a 10 mg per milliliter (ml) elixir (suspension). Which could be given at 0.5 ml for the 5 mg dose. On 9/16/24 at 11:30 AM, V4 Registered Nurse (RN) removed R2's Doxepin bottle from the medication cart and one from storage. Both bottles showed Doxepin 10 mg capsules. V4 stated the medication comes in capsules which could not be cut in half like a tablet. V4 stated if a medication and order do not match we need to contact the physician to verify the order, and possibly hold the dose until we get the correct medication. V4 stated R2's Doxepin has always come in 10 mg capsules. V4 stated R4 has never had a liquid version of Doxepin. On 9/16/24 at 12:35 PM, V5 Licensed Practical Nurse stated R2 has always had 10 mg capsule for his Doxepin dose. V5 stated if a medication does not match the order the physician an pharmacy need to be notified so the order can be verified, and the medication can be changed to the correct dose if needed. (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: 145727 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 145727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064 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)