F0689

D

Failure to Control Resident Substance Use and Reassess Community Pass Privileges

Freeport, Illinois Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent and supervise a resident from ingesting cannabis and to reassess another resident’s community pass privileges for safety. A posted safety and security notice at the reception desk stated that personal items may be inspected when there is reasonable cause for concern about prohibited or unsafe items such as illegal substances and contraband. One resident (R1) had diagnoses including seizures, schizoaffective bipolar disorder, post-traumatic stress disorder, suicidal ideations, prior poisoning by unspecified drugs with intentional self-harm, unspecified mood disorder, and epilepsy, as well as a known history of substance abuse and prior positive THC screens. Hospital records from a recent transfer documented that R1 appeared more confused, was slurring her words, and had a urine toxicology screen positive for marijuana; R1 reported she may have taken “gummies or something” and later told surveyors she was getting gummies from another resident (R2). R1’s current care plan did not include her history of substance abuse.

Staff interviews showed that CNAs were aware of rumors of residents using illegal substances in the facility but had not personally observed contraband, and management had not discussed the posted contraband sign with them. Nursing staff reported that on the day of R1’s hospital transfer, she was very lethargic and not acting like herself, leading to her being sent out and again testing positive for THC, with uncertainty about how she obtained the substance. The DON acknowledged R1’s history of substance abuse and prior positive THC tests but stated she was not sure how R1 was getting the substance and was not aware of residents using substances in the facility. The Administrator stated that R1 reported getting gummies from another resident, while that resident denied providing them. Staff also reported that R1 frequently attempted to go into R2’s room without a clinical reason, and nursing staff redirected her back to her own room.

The facility also failed to reassess and manage community pass privileges for R2 despite documented concerns about substance use. R2 had diagnoses including unspecified cirrhosis of the liver, alcohol abuse, insomnia, and major depressive disorder, and his record showed an order for a urine drug screen that was never completed because he was either out of the building or unable to provide a specimen. R2’s community survival skills assessment indicated he was capable of outside pass privileges, and he reported going out independently, consuming alcohol on occasion when out, and being able to leave when he pleased. Staff, including a CNA and an RN, stated that R2 “does his own thing,” leaves the facility when he wants, and that they had heard he goes to bars and drinks. The DON stated R2 was independent and did not need supervision, and social services reported that residents who violate pass standards should lose independent pass privileges but was not aware of R2 using substances. A psych NP documented that R2 had a history of alcohol abuse, was currently using illicit substances such as alcohol and possibly cocaine, refused urine drug screening, was refusing antipsychotic medication, and might be using substances during community passes. The facility’s community pass policy stated that using alcohol or illicit substances or bringing them into the facility is prohibited and may result in forfeiture of pass privileges, and that the facility reserves the right to revoke passes if a resident is assessed as a threat to self or others.