Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observations, interview, and record review the facility failed to provide a clean and sanitary
home-like environment for 143 residents currently residing on the facility's first and second floor units.
Residents Affected - Some
Findings include:
On 11/17/24 at 11:10 AM, Surveyors were provided the facility census that listed 216 residents currently
residing in the facility, whereas 143 residing on the first and second floor units.
On 11/17/24 at 09:15 AM, Surveyor sensed strong odor upon entrance to the first floor unit common area.
On 11/17/24 at 11:11 AM, Surveyor observed an empty medicine cup and empty milk cartoon on the
elevator's floor. Surveyor observed wet, yellow, puddle, smelling like urine in the common area upon exit
from the elevator on the second floor. Surveyor sensed strong urine odor on the second floor. Low side of
the second floor unit floors noticed to be sticky.
On 11/17/24 at 02:38 PM, Surveyor interviewed V36 (Housekeeper) who said in the summary, I am
assigned to the second floor. We always have two housekeepers on the second floor unit except today, the
other housekeeper was off today. My assignment consists of removing the trash, moping nursing station,
hallways, and then I move on to the common area bathroom, and then residents individual rooms. The
stench is from the residents who don't shower, my assigned area is clean. Cleaning elevators falls under 1st
floor housekeeper. As a rule of thumb, if it's urine, feces, or blood, I am not to clean it, it is certified nurse
assistant's responsibility. I cleaned the urine puddle today with bleached towel, but I really don't know how
to do it, nobody told me how to clean body fluids.
On 11/18/24 at 11:26 AM, Surveyor interviewed V14 (Housekeeping Director) who said in the summary, the
facility seems cleaner and smells better today because there are more housekeepers in the facility.
Generally, there are more housekeepers scheduled to work from Monday through Friday. There are five
housekeepers from Monday through Friday, from 7:00 AM to 3:00 PM: two housekeepers on the 3rd floor,
two housekeepers on the 2nd floor, and one housekeeper on the 1st floor. Then there are two to three
housekeepers from 3:00 PM to 8:00 PM. On Saturdays and Sundays there are three to four housekeepers
from 7:00 AM to 3:00 PM and two housekeepers between 3:00 PM to 8:00 PM. As far as cleaning urine and
feces, certified nurse assistants should pick up the bulk of it and then the housekeepers supposed to
sanitize the floor. I know we have special kits to clean blood. But you know, urine puddles happen all the
time in the facility, residents pee on the floor all the time, so we (housekeepers) just clean it up.
(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 7
Event ID:
145784
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
145784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briar Place Nursing
6800 West Joliet
Indian Head Park, IL 60525
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 11/20/2024 at 1:56 PM, Surveyor interviewed V1 (Administrator) who said in the summary, cleaning
body fluids is mutual responsibility of housekeepers and nursing staff. Nursing staff should pick up the bulk
of soil, for example urine or feces, and then call housekeeping to disinfect.
The facility Blood and Body Fluid Spills Clean Up Procedure (no date) reads in part In the event of a spill of
blood, body fluid or tissues occurring on any environmental surface (Bed, floor, table, etc.) the employee will
secure a Blood and Body Fluid Clean Up Kit.
Event ID:
Facility ID:
145784
If continuation sheet
Page 2 of 7
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
145784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briar Place Nursing
6800 West Joliet
Indian Head Park, IL 60525
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 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to provide one resident (R85) with adequate
supervision during a shower. This resulted in R85 experiencing a seizure which led to her arm getting stuck
in the handrail causing her to fracture her humerus.
Findings Include:
R85 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in
the facility. R85 has multiple diagnoses including but not limited to the following: Epilepsy, right humerus
fracture, bipolar disorder, paranoid schizophrenia, mood disorder, anxiety, pain, and depression.
Facility Reported Incident with date of 10/9/24 states in part but not limited to the following: R85 noted in
shower room with right arm between shower rail and wall, R85 noted with pain, shortening, and abnormal
rotation to right arm. R85 transferred to hospital for further evaluation and treatment.
Hospital records dated 10/10/24 shows R85 arrived at the hospital from facility after an unwitnessed
seizure in the shower. R85 complaining of pain after she fell to the right shoulder that showed deformity and
fracture.
On 11/18/2024 at 10:40AM, R85 was interviewed regarding incident on 10/9/24. It is to be noted that R85
was noted to be in bathroom by herself.
R85 stated, On 10/9/24, I was taking a shower independently in the shower room when I had a seizure.
R85 said I felt the seizure coming on but I could not get to the call light as it was across the shower. I could
not sit down because the shower chair was broken and not safe to sit on. I always take showers
independently with no supervision. My arm got caught in the handrail while I was seizing. I had to be there
seizing for at least 20 minutes before V11 (Registered Nurse) came to check on me. My entire body was
bruised and black and blue. V32 (Maintenance Director) had to come and take the handrail off the wall
because my arm was so wedged into the rail. I had fractured my right upper arm and must wear an
immobilizer.
It is to be noted that R85 was alone in her room and dressed herself independently after this interview.
At 10:55AM, V11 was interviewed regarding R85's incident on 10/9/24. V11 said the shower rooms are
always locked. The staff must let the residents into the shower room to ensure they are aware of who is in
there.
V11 said I was at the nurses' station talking to a family member when I heard crying and whimpering
coming from the shower room. R85 was in the shower room for about 20 minutes before I heard R85
crying. R85 always showers independently. When I entered the shower room, I saw R85 in the shower
closest to the door on the left. Her arm was wedged in between the handrail. We had to call maintenance to
take the side rail out to get her arm out. We immobilized her arm and sent her to the hospital.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145784
If continuation sheet
Page 3 of 7
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
145784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briar Place Nursing
6800 West Joliet
Indian Head Park, IL 60525
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 0689
Progress notes written by V11 on 10/9/2024 were reviewed and correlates to what V11 said in interview.
Level of Harm - Actual harm
Per Minimum Data Set, dated [DATE] shows R85 required supervision/touching assistance while
showering. R85 care plan states in part but not limited to the following: R85 has a self-care deficit in
ADLs/mobility related to epilepsy, seizures, etc. Interventions include supervise in shower for safety, dated
3/20/2024.
Residents Affected - Few
On 11/20/24 V35 (Medical Director/Attending Physician) was interviewed. V35 said a resident with a
diagnosis of epilepsy and uncontrolled seizures, meaning the resident has had seizures within the last six
months, should be supervised in the shower for safety.
Prior to incident on 10/9/2024, it is to be noted that per progress notes, R85 has had seizures on
9/20/2024, 9/9/2024, 8/1/2024, 7/13/2024, 6/28/2024, 6/27/2024, 6/3/2024, and 5/2/2024.
Facility Policy titled Resident Supervision dated 01/2024 states in part but not limited to the following:
Supervision is followed per the plan of care in accordance with individualized resident focused approach.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145784
If continuation sheet
Page 4 of 7
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
145784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briar Place Nursing
6800 West Joliet
Indian Head Park, IL 60525
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to follow their own pharmacy's policy on
expiration dating for medications in vials by failing to date two opened vials of insulin found inside the
facility's second floor storage room refrigerator, potentially affecting two residents (R51 and R130) reviewed
for drug storage.
Findings include:
On [DATE] at 10:55 AM, accompanied by V16 (Agency Licensed Practical Nurse), one opened vial of
insulin Glargine belonging to R51 and one opened vial of insulin Lispro belonging to R130 were found
inside the facility's second floor storage room refrigerator, and neither vial was dated.
On [DATE] at 10:56 AM, V16 said insulin had to be dated upon opening to know when it expired because
insulin had a shortened expiration time and only stayed potent and worked for 28 days after opening the
vial.
On [DATE] at 11:06 AM, V2 (Director of Nursing) said medications were dated based on the
recommendation of the medication. V2 also said if a medication had a recommended usage time of 28
days, they would need to know the open date to determine the proper expiration date in order to know
when to discard the medication because the medication was only effective during that time, otherwise it
would lose its effectiveness.
Per R51's medication administration record, (MAR) for the month of [DATE], insulin Glargine solution, 100
unit/mL, had been administered one time per day, for diabetes, at 25 units, subcutaneously, from [DATE] to
[DATE].
Per R130's medication administration record, (MAR) for the month of [DATE], insulin Lispro solution, 100
unit/mL, had been administered before meals at 11:00 AM, for diabetes, at 10 units, subcutaneously, and
per sliding scale before meals and at bedtime, subcutaneously, from [DATE] to [DATE].
The facility's Pharmacy Policies and Procedures Manual, last revised [DATE], stated, When the original seal
of a manufacturer's container or vial is initially broken, the container or vial will be dated. The same policy
also read, The nurse shall place a 'date opened' sticker on the medication and enter the date opened and
the new date of expiration, and, The expiration date of the vial or container will be 30 days. Lastly, the policy
stated, Certain medications or package types, such as multiple dose injectable vials, once opened, require
an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145784
If continuation sheet
Page 5 of 7
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
145784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briar Place Nursing
6800 West Joliet
Indian Head Park, IL 60525
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interview, and record review the facility failed to follow the hand hygiene policy. This
failure has a potential to affect all 216 residents currently residing in the facility.
Residents Affected - Many
Findings include:
On 11/17/24 at 11:10 AM, Surveyors were provided the facility census that listed 216 residents currently
residing in the facility.
On 11/18/24 at 10:34 AM, Surveyor observed, third floor unit, V20 (Certified Nurse Assistant) walking out of
a resident's room the third floor unit without performing hand hygiene. Surveyor interviewed V20 (CNA) who
said in the summary, there are no hand sanitizers in the hallways or residents' rooms due to residents'
cognitive condition, resident use to try to drink hand sanitizer. We are supposed to always have
personalized hand sanitizers in our pockets. I don't have a hand sanitizer with me right now. Surveyor
further inquired how did V20 (CNA) sanitize hands upon exiting resident's room, V20 (CNA) said, I have no
way to sanitize my hands right now.
On 11/18/24 at 11:13 AM, surveyor observed V5 (Wound Care Nurse) perform wound care for R270. V5
(Wound Care Nurse) removed large dressing with copious amount of foul smelling drainage. V5 did not
remove soiled gloves after cleaning wound, applied treatment and then removed soiled gloves and donned
a clean glove without performing hand hygiene. Further, V5 cleaned bowel movement from R270's buttocks,
removed glove from the right hand and then donned a new glove without performing any hand hygiene.
On 11/18/24 at 11:40 AM, surveyor inquired V5 (Wound Care Nurse) about hand hygiene related to the
sacral wound dressing change. V5 said, I should have sanitized my hands.
On 11/19/24 at 10:43 AM, Surveyor interviewed, second floor unit, V17 (Certified Nurse Assistant) who said
in the summary, we usually carry personalized hand sanitizer in our scrub's pocket to maintain hand
hygiene. I don't have personalized hand sanitizer with me right now.
On 11/19/24 at 11:18 AM, Surveyor observed V17 (Certified Nurse Assistant) going in and out of two
residents' rooms the second floor unit without performing hand hygiene.
On 11/19/24 at 10:49 AM, Surveyor interviewed, first floor unit, V18 (Certified Nurse Assistant) who said in
the summary, there are no sanitizers in the common unit areas and residents' rooms, we are supposed to
have a bottle of personalized hand sanitizer. V18 (CNA) grabbed a bottle of a personalized hand sanitizer
from the nursing station desk and slipped it into her scrub's pocket while talking to the surveyor.
On 11/19/24 at 12:03 PM, Surveyor interviewed V6 (Infection Preventionist) who said in the summary, I talk
to staff about hand hygiene, I tell them when the hand hygiene should be done and how long should it take
to wash and/or sanitize hands. Last hand hygiene in-service was done in October 2024. We don't have
hand sanitizers in the hallways and residents' rooms. There are residents who will attempt to drink it due to
their cognitive limitations or mental diagnosis. Staff should always carry their own hand sanitizers. I stack
personalized hand sanitizers in nursing station on each unit on all three floors to make sure hand sanitizers
are readily available. Staff should sanitize their hands
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145784
If continuation sheet
Page 6 of 7
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
145784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briar Place Nursing
6800 West Joliet
Indian Head Park, IL 60525
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
to prevent spread of infections. Staff should always sanitize their hands upon entering and exiting residents'
rooms, unless their hands are visibly dirty, then staff should wash their hands with soap and water.
Additionally, staff should perform hand hygiene before and after providing resident care, before and after
passing, meal trays, etc.
The facility Hand Hygiene policy dated 01/01/2020 reads in part, The use of gloves does not replace hand
hygiene. Hand hygiene is always the final step after removing and disposing of personal protective
equipment (PPE). Using alcohol-based hand gel; If hands are not visibly soiled, use an alcohol based hand
rub for all the following situations: Before applying gloves and after removing gloves or other PPE; After
providing direct patient care; before handling clean or soiled dressing, gauze pads, etc; After contact with
inanimate objects (e.g., medical equipment) in the immediate vicinity of the resident.
Event ID:
Facility ID:
145784
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations 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.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the November 20, 2024 survey of BRIAR PLACE NURSING?
This was a inspection survey of BRIAR PLACE NURSING on November 20, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIAR PLACE NURSING on November 20, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.