Health inspection·August 12, 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 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 Page 1 of 3 145795 145795 08/12/2025 Tower Hill Healthcare Center 759 Kane Street South Elgin, IL 60177

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 145795 Page 2 of 3 145795 08/12/2025 Tower Hill Healthcare Center 759 Kane Street South Elgin, IL 60177

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 145795 Page 3 of 3