Health inspection·June 2, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure consents for administration were obtained prior to administering anti-psychotic and anti-anxiety medications. This applies to 1 of 4 residents (R2) reviewed for psychotropic medications in the sample of 6. The findings include: R2's Census Report shows R1 originally admitted to the facility on [DATE] and left the faciity on 5/4/25 for a hospital stay. R2 returned to the facility on 5/11/25. R2's Hospital Discharge Paperwork dated 5/1/25 shows R2 was ordered to take escitalopram oxalate 20 milligrams (mg) one tablet daily and trazodone 50 mg one tablet nightly as needed. R2 was not ordered to take quetiapine while at the hospital or upon discharge from the hospital. On 6/2/25 at 12:15 PM, V8 (R2's Family Member) could not recall the facility providing V8 with a consent form to sign to provide V8 with quetiapine. V8 said V11 (R2's Son) and R2 were also both unaware of receiving a consent form to be administered quetiapine. V8 said while R2 has been taking quetiapine at the facility, R2 has not experienced any negative reactions and R2's behavior, mood, and speech have improved. 1. R2's May 2025 Medication Administration Record (MAR) shows R2 received quetiapine fumarate 50 mg at bedtime on 5/3/25. Facility provided consent for psychotropic medication use form for quetiapine fumarate, dated 5/1/25, does not have a signature from R2, V8, or V11 and does not show that V8 or V11 provided verbal consent over the phone for R2 to receive quetiapine fumarate. Facility provided consent for psychotropic medication use form for quetiapine fumarate, dated 5/13/25, shows R2 consented to receiving 50 mg quetiapine twice daily; once in the morning and once at bedtime, for a total of 100 mg. 2. R2's May 2025 Medication Administration Record (MAR) shows R2 received escitalopram 20 mg once daily for depression on 5/2/25 and 5/3/25. Facility provided consent for psychotropic medication use form for escitalopram, dated 5/1/25, does not have a signature from R2, V8, or V11 and does not show that V8 or V11 provided verbal consent over the phone for R2 to receive escitalopram. Page 1 of 2 146195 146195 06/02/2025 Ignite Medical McHenry 550 Ridgeview Drive McHenry, IL 60050

F 0605 Level of Harm - Minimal harm or potential for actual harm Facility provided consent for psychotropic medication use form for escitalopram, dated 5/12/25, shows R2 consented to receive escitalopram 20 mg daily. 3. R2's May 2025 Medication Administration Record (MAR) shows R2 received trazodone 50 mg once daily at bedtime for anxiety on 5/1/25, 5/2/25, and 5/3/25. Residents Affected - Few Facility provided consent for psychotropic medication use form for escitalopram, dated 5/1/25, does not have a signature from R2, V8, or V11. On the bottom of the form, with a date of 5/11/25, a signature from V8 was provided for R2 to receive trazodone 50 mg once daily. Facility provided consent for psychotropic medication use form for escitalopram, dated 5/16/25, shows R2 consented to receive trazodone 50 mg nightly for insomnia. On 6/2/25 at 3:39 PM, V13 (RN/Assistant Director of Nursing- ADON) said consents should be obtained prior to administering medications such as an anti-psychotic, an anti-anxiety, and an anti-depressant. Even if a resident admits to the hospital and was taking these medications at the hospital, the facility should still receive consent to administer these medications before administration. Facility Psychotropic Medications policy dated 12/2019 states, . Any and all psychotropic medication orders will be initiated by the facility only after the physician has completed and returned an Informed Consent related to the drug with the elder and/or responsible party/family. The drug order will include a start date on completion of the Informed Consent form . 146195 Page 2 of 2