Health inspection·August 7, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide notification when R1's psychiatric medication was discontinued for 1 of 9 residents reviewed for notification in the sample of 9.On 08/06/2025 R1 was not in the facility.R1's MDS-Minimum Data Set, dated [DATE] shows, R1's Brief Interview for Mental Status shows, moderately impaired.R1 has multiple diagnoses including, ADHD-Attention Deficit Hyperactivity Disorder, traumatic brain injury, dementia.On 08/06/2025 at 9:30AM, V6 R1's Husband said, a few years ago R1 had a cardiac event and lost consciousness. As she fell, she hit the front part of her head; we lost a large part of who she was. R1 has a diagnosis of ADHD. I do not know why the facility did not notify me of this change in treatment. R1 currently lives in Assisted Living with me. It allows me to care for her and prepare our house for sell. I contacted R1's psychiatrist. The psychiatrist said the treatment should not have been stopped. I would think the facility's physician would contact the treating specialist prior to stopping psychiatric treatment.On 08/07/2025 at 08/07/2025 12:59PM, V1 Administrator said, the physician's progress note was taken as the order to stop R1's medication. I do not have documentation that shows the resident, or family was notified of the medication change.R1's Physician's Progress Note dated 07/14/2025 by V8 Medical Doctor shows, ADD-Attention Deficit Disorder- Stable, STOP lisdexamfetamine, patient prescribed medication by psychiatrist as outpatient. Page 1 of 2 146195 146195 08/07/2025 Ignite Medical McHenry 550 Ridgeview Drive McHenry, IL 60050

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure R1 and R2 had a Physicians Order for the use of a CPAP-Continuous Positive Airway Pressure machine for 2 of 3 resident (R1,R2) reviewed for Respiratory Services in the sample of 9. 1.On 08/06/2025 at 10:18AM, R2 was lying in bed. R2's CPAP-Continuous Positive Airway Pressure device was on the bedside.On 08/06/2025 at 10:18AM, R2 said, my family set up the CPAP machine for me. The facility keeps the machine filled with distilled water. I put it on myself.R2's Physician's order dated 07/11/25 shows, Respiratory Therapy evaluate and treat if indicated.On 08/07/2025 at 3:00PM, V5 RT-Respiratory Therapy said, R1, R2, and R3 all use their home CPAP machines. As respiratory therapy we do not do anything with the resident's home machine. The Nursing staff contacts the physician for an order for the CPAP; the physician's order also contains the prescribed settings needed for the machine to operate correctly.R2's Physician's Orders on 08/06/2025 shows, R2 did not have an order for a CPAP machine.2.On 08/06/2025 R1 was not in the facility.On 08/06/2025 at 9:30AM, V6 R1's Husband said, I brought R1's CPAP machine to the facility. I showed the CNA-Certified Nursing Assistant how to use it. The CNA brought distilled water to the room. When I returned the next day the CPAP tank was dry; the gallon of distilled water was not open. No one helped R1 to apply her CPAP at night.On 08/06/25 at 1:56PM, V4 RN-Registered Nurse said, we get report from the hospital a resident is arriving with a CPAP. It is often written in the hospital discharge instructions. RT is not here all the time. If I see the resident has a CPAP at the bedside I will ask if they are using it. I will call the doctor and get an order. The Physician's Order populates in the Medication Administration Record and prompts the nurse to apply the CPAP or check that it is on and functioning.R1 Physician's Orders dated 07/03/2025 to 07/25/2025 shows, R1 did not have a Physician's Order for a CPAP.R1's Physician's Progress Notes dated 07/14/2025 shows, R1 has a multiple diagnosis including obstructive sleep apnea.R1's Hospital discharge Record dated 07/29/2024 shows, R1 is CPAP dependent.R1's Follow-Up by Nurse Practitioner Visit dated 07/22/2025 shows, patient reports she uses a CPAP every night.The facility's Respiratory Supplies policy reviewed 11/2024 shows, the policy does not address the need for a physician order for respiratory treatment. Residents Affected - Few 146195 Page 2 of 2