Sunny Hill Nursing Home Of Will County

Ensure that residents are fully informed and understand their health status, care and treatments.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor the wishes of a POA (Power of Attorney) by not administering an antidepressant medication.

This applies to 1 of 1 resident (R3) reviewed for medications.The findings include: R3's admission Record showed R3 was admitted to the facility on [DATE].

R3 had multiple diagnoses which included congestive heart failure, cognitive communication deficit, major depressive disorder, and osteoarthritis.On 12/31/25 at 3:28 PM, V10 (RN/Registered Nurse) stated on 12/03/25, she received an order from the NP (Nurse Practitioner) to give R3 Zoloft (Antidepressant medication). V10 stated the order was delegated to the next shift, and the order was carried out. V10 stated she spoke with R3's POA and he stated he did not want Zoloft administered to R3. V10 stated she forgot to discontinue the medication from the EMR (Electronic Medical Record). V10 stated R3's POA did not give consent for Zoloft, but the medication was started a few days later. On 12/31/25 at 4:02 PM, V2 (DON/Director of Nursing) stated V10 did not discontinue the order for Zoloft. V2 stated V10 forgot about it and the medication was still on the MAR (Medication Administration Record) and the LPN's (Licensed Practical Nurse) gave the medication without consent. V2 stated R3's POA found out that R3 had been taking Zoloft at the care plan meeting. R3's Order Audit Report dated 12/31/25 showed Zoloft 25 mg (milligrams), give one tablet by mouth at bedtime was ordered on 12/03/25.

The same report showed Zoloft 25 mg was discontinued on 12/18/25 per R3's POA's request.

The MAR (Medication Administration Record) for December 2025 showed R3 was administered Zoloft 25 mg at bedtime on 12/05-12/17/25. R3's Progress Notes dated 12/03/25 at 5:11 PM, showed Resident seen by (Name) NP this morning with new orders to start Zoloft 25 mg one tablet PO (by mouth) nightly.

Progress Notes dated 12/04/25 at 11:00 AM, showed Spoke with resident's POA (Name) about the new order of NP (Name) Zoloft for depression. (Name) declined the new medication, he verbalized his uncle has been verbalizing negative/depressive thoughts for years. POA does not want additional medications now. R3's Progress Notes dated 12/18/25 at 1:38 PM, showed During care plan meeting, while going over medication Zoloft, POA became upset stating he declined this medication so it should not have been given. POA stated I do not want to attend these meetings any longer.

These meetings are not effective, your staff just does the opposite of what I request.The facility's Psychotropic Medication Policy reviewed date 12/20/23 showed, Nursing: 1.

Obtains all consent for as required by regulation from the POA.

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.

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