Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 antidepressant medication was obtained from the
pharmacy in a timely manner to prevent a resident from missing medication doses as ordered by the
physician.This applies to 1 of 3 residents (R1) reviewed for quality of care in the area of missing
antidepressant medications in the sample of 5.The findings include:The EMR (Electronic Medical Record)
shows R1 was admitted to the facility on [DATE], and was discharged to home on July 1, 2025. R1 had
multiple diagnoses including, traumatic brain injury with loss of consciousness, anoxic brain damage, other
specified depressive episodes, Parkinsonism, psychoactive substance dependence, generalized anxiety
disorder, depressive episodes, atrial fibrillation, and anemia. R1's MDS (Minimum Data Set) dated June 30,
2025 shows R1 had moderate cognitive impairment, required setup assistance with toilet hygiene and
showering, and supervision with all other ADLs (Activities of Daily Living). R1 was always continent of
bowel and bladder. A Plenary Letter of Office Guardian for Disabled Person shows R1 as a disabled person
and V13 (Mother of R1) and V15 (Father of R1) as the permanent guardians for R1.The EMR shows the
following order dated April 16, 2025: Venlafaxine Hydrochloride (Effexor) (antidepressant medication),
Extended-Release 24-hour. Give 37.5 mg. (milligrams) by mouth one time a day for depression. The order
was discontinued by facility staff on June 14, 2025 at 11:43 AM.The EMR shows the following order dated
June 16, 2025: Venlafaxine HCL (Hydrochloride) ER (Extended-Release) 24-hour 37.5 mg, give 1 tablet by
mouth one time a day for depression.On May 6, 2025, at 11:55 AM, V9 (RN-Registered Nurse)
documented, Venlafaxine HCl ER Tablet Extended-Release 24-hour 37.5 mg. Give 1 tablet be mouth one
time a day for depression. On Order.On May 21, 2025, at 9:30 AM, V8 (LPN-Licensed Practical Nurse)
documented, Venlafaxine HCl ER Tablet Extended-Release 24-hour 37.5 mg. Give 1 tablet be mouth one
time a day for depression. NA (Not Available).On June 11, 2025, at 9:24 AM, V9 (RN) documented,
Venlafaxine HCl ER Oral Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for
depression. Not available.On June 10, 2025, at 9:28 AM, V8 (LPN) documented, Venlafaxine HCl ER Oral
Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for depression. NA.On June
13, 2025 at 1:57 PM, the facility's pharmacy sent the following notification to the facility dated June 13,
2025: Attention Medication Coordinator: The medication prescribed is not covered by insurance or may
require a prior authorization. Resident: R1. Medication prescribed: Venlafaxine Tab 37.5 ER, Give 1 tablet
by mouth daily for depression. The Resident's insurance prefers the following alternative medication(s):
Venlafaxine Cap 37.5 ER. Please have the provider review alternative medications. If approved, discontinue
order, and send a new order for the alternative medication. Please reply by email or fax if: No changes reason. Please send prescribed medication. I am aware of the issue referenced above. Please note, facility
may incur bill of $21.88. Admin/DON (Director of Nursing) Name and Signature. Please note lack of action
may result in delays in receiving medication.On June 14, 2025, at 11:56 AM, V11 (LPN) documented,
Venlafaxine HCl
(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 3
Event ID:
145795
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
145795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tower Hill Healthcare Center
759 Kane Street
South Elgin, IL 60177
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
ER Oral Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for depression.
Medication reorder to capsule instead of tablet.The facility's Order Audit Report dated June 14, 2025, at
11:41 AM shows V11 entered the following order for R1: Venlafaxine HCl ER Oral Capsule
Extended-Release 24-Hour, Give 1 mg. by mouth one time a day for depression.The pharmacy sent a
second notification to the facility regarding R1's Venlafaxine, dated June 14, 2025. The notification shows
the medication order needed clarification because the Venlafaxine was ordered as 1 milligram by mouth
one time a day. The above prescribed medication needs clarification from the prescriber: Verify dose, 1 mg.
is not available in the market.On June 15, 2025, at 8:16 PM, V12 (RN) documented, Resident returned from
pass with his parents.Mother (V13) also asked if Effexor had been received and as of yet, it has not been
received. Mother would like [V14] (NP-Nurse Practitioner) to see [R1] in the morning regarding Effexor.The
facility's Order Audit Report dated June 16, 2025, at 3:29 AM shows V19 (LPN) entered the following order
for R1: Venlafaxine HCl ER Oral Capsule Extended-Release 24-Hour. Give 37.5 mg. by mouth one time a
day for depression.On June 16, 2025, at 8:33 AM, V12 (RN) documented, Called pharmacy to follow-up on
delivery of Effexor and per pharmacy they have it showing to be delivered today at 11:00 AM. Will check
then to ensure delivery.On June 16, 2025 at 11:00 AM, V10 (LPN) documented: Venlafaxine HCl ER Oral
Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for depression. NA. Ordered
from pharmacy will be delivery today.Pharmacy documentation shows R1's Venlafaxine was delivered to
the facility on June 16, 2025 at 3:44 PM. The facility does not have documentation to show R1 received his
dose of Venlafaxine on June 16, 2025.On June 16, 2025 at 11:50 AM, V14 (NP) documented, The patient
(R1) was seen and evaluated today. He appeared slightly anxious and expressed concern regarding his
current care, specifically related to a lapse in his medication regimen. The patient reported that his Effexor
was abruptly discontinued due to pharmacy complications, resulting in an unplanned cessation for
approximately five days without tapering.On August 11, 2025 at 11:53 AM, V2 (DON) said, [R1's] parents
brought medications from home when he was admitted . Our policy shows there must be a physician order
to use home medications. We did not have a physician order to give medications from home to R1. At some
point the family requested we obtain the medication for [R1] from our pharmacy. When it was time for us to
get the medication from the pharmacy, the pharmacy was not covering the tablet form of the medication.
Once we ordered the capsule form, we received the medication. I was not in the building at the time of this
situation, and I am not sure who was handling the pharmacy notifications in my absence.On August 11,
2025 at 12:13 PM, V16 (Pharmacy Customer Service Representative) said, We sent the Venlafaxine
capsules to the facility on June 16, 2025. We sent a 30-day supply. That was the first time we ever sent that
medication to the facility.On August 11, 2025 at 12:21 PM, V18 (Pharmacist) said, the pharmacy sent a fax
to the facility on June 13, 2025 for clarification of R1's Venlafaxine order due to R1's insurance refusing to
pay for the tablet form of the medication and preferring to pay for the capsule form. The facility ordered the
medication, but with the wrong dosage, and the pharmacy had to send a second form to the facility to
clarify the Venlafaxine order since the order was sent to the pharmacy as 1 milligram and 1 milligram is not
a dosage available in the market for Venlafaxine. V18 said, We had to wait to get a response from the facility
before we filled the medication. The facility finally responded on June 16, 2025 with an order for the
capsules, and then we filled the prescription that same day.The facility's policy entitled Medications Not
Covered by Third-Party Payers, revised January 2018 shows: Policy: When a non-covered (non-formulary)
medication is ordered for a resident eligible for medication-related benefits under Medicaid, Medicare, or
other third-party payer programs, the provider pharmacy attempts to have the order changed to a covered
(formulary) medication or to have the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145795
If continuation sheet
Page 2 of 3
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
145795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tower Hill Healthcare Center
759 Kane Street
South Elgin, IL 60177
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
medication covered under a medical necessity waiver or other procedure, as state law allows. Payment
coverage determinations shall not delay timely availability of medications unless the prescriber authorizes
the medication to start when it becomes available. Procedures: A. When non-covered medications are
ordered, the provider pharmacy or licensed nurse consults with the resident's physician to seek a change to
a covered item. B. If the physician elects not to change the order, and if appropriate, the physician is asked
to document medical necessity according to the process set forth by the third-party payer. The pharmacist
then attempts to obtain coverage following third-party payer procedures. C. If coverage is not available and
third-party rules permit, the pharmacy bills the resident or responsible party, or the facility, as allowed by
state law and per the facility's pharmacy provider agreement.
Event ID:
Facility ID:
145795
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the August 12, 2025 survey of TOWER HILL HEALTHCARE CENTER?
This was a inspection survey of TOWER HILL HEALTHCARE CENTER on August 12, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TOWER HILL HEALTHCARE CENTER on August 12, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.