Health inspection·September 11, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders and failed to follow the facility community pass policy after no credible evidence of contraband was found for one (R72) resident. This failure affected one resident (R72) in a sample of 72 residents. Findings include:R72 is [AGE] years of age with diagnoses include not limited to: Alcohol Abuse, Anxiety Disorder, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Post- Traumatic Stress Disorder, Chronic, Suicidal ideations, Anemia, Unspecified, Insomnia, Unspecified, Other Psychoactive Substance Abuse, Uncomplicated, Schizophrenia, UnspecifiedSection C - Cognitive Patterns (7/6/2025) documented BIMS 15 (cognitively intact)R72's physician orders document an active physician order for independent community pass.R72's Community Survival Skills Assessment documents (in part) Effective 9/9/2025 at 08:51 9. Documents 2. Cannot Determine B. Recommendations and Outcomes 1. Recommendations 2. The resident does not appear to be capable of unsupervised outside pass privileges at this time. (9/9/2025) Residents independent community access restricted for 30 daysR72's progress notes (9/10/25) authored by V33 (Psychosocial Rehabilitation Services Coordinator) documents in part that V33 had suspicion that R72 had contraband and staff searched R72's room. Nothing was found. Staff attempted to receive a urine sample and R72 refused and got agitated, ultimately requesting a transfer in nursing home. There is no documentation with R72's medical record that indicates that R72 had any symptoms of being under the influence of any illicit substance or other indications that R72 was in possession of any illicit substance.On 9/11/2025 at 11:12 AM, R72 was visibly upset and explained that R72's community pass was restricted a couple days ago after another resident made up a story about R72 bringing a marijuana pen into the facility. R72 stated, I didn't do anything wrong, I went out for a couple hours and came back. (R17) was jealous or something that I went out on pass and told them I had a weed pen to get back at me. I don't have a weed pen, I don't smoke. They (facility staff) came in and searched my room and didn't find anything but (V33) still took my pass away. It's not fair they have no reason to take away my pass!On 9/11/2025 at 1:29 PM, V33 (Psychosocial Rehabilitation Services Coordinator) affirmed that V33 is the social worker assigned to R72 and was the staff member that restricted R72's community pass. R72 explained that another resident had said R72 had a weed (marijuana) pen. R72 searched the room and there was no weed (marijuana) pen found. R72 was agitated after the staff searched R72's room and wouldn't give a urine sample so the V33 restricted R72's community pass. V33 affirmed that there were no other indications that R72 may have been under a controlled substance other than agitation. V33 was unsure if there was anything that R72 signed that consented for forced drug testing or if it was part of the community pass program.On 9/11/2025 at 2:58 PM, V34 (Psychiatrist) affirmed that V34 is a psychiatrist for the facility. V34 explained that residents under the effects of marijuana present differently, but marijuana typically produces a calming effect (not agitation). In some cases, marijuana can cause hallucinations and psychosis.Review of the Page 1 of 2 145784 145784 09/11/2025 Briar Place Nursing 6800 West Joliet Indian Head Park, IL 60525

F 0550 Level of Harm - Minimal harm or potential for actual harm community pass program policy that were signed by R72 documents in part that pass privileges will be taken away for a minimum of 30 days if R72 comes back from pass intoxicated or under the influence of drugs and that drug testing can be completed if the resident comes back from an overnight community pass and is suspected to be under the influence (R72 was not out of the facility overnight). Residents Affected - Few 145784 Page 2 of 2