F0689

K

Failure to Control Illicit Drug Use and Provide Adequate Supervision Leading to Overdoses and Falls

Chicago, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor, supervise, and intervene for multiple residents with known substance use disorders, and to provide adequate supervision to prevent accidents such as falls. Several residents with documented histories of opioid and other substance abuse were able to obtain and use illicit drugs within the facility, resulting in episodes of unresponsiveness and suspected overdoses. One resident with diagnoses including opioid dependence, anxiety disorder, obstructive sleep apnea, and major depressive disorder was found unresponsive during morning rounds with no respirations or pulse, and resuscitation efforts were unsuccessful. Another cognitively intact resident reported that this resident had overdosed, was found on the floor with liquid coming from his nose, and that staff did not check purses or conduct searches, making it easy to bring drugs into the building. Multiple residents and staff reported that this was not the first overdose death in the facility and that drugs such as heroin and crack cocaine were being sold by residents on specific units.

Additional residents with substance use histories experienced overdoses or suspected overdoses while in the facility. One resident with a history of opioid abuse and withdrawal admitted to buying cocaine inside the facility and reported being given Narcan after overdosing. Another resident with diagnoses including abuse of psychoactive and non-psychoactive substances, and opioid abuse in remission, admitted to substance use and possession of contraband on more than one occasion, with contraband baggies found in the room and Narcan reportedly administered after an overdose requiring hospitalization. A resident with opioid abuse reported that illegal drugs, including crack cocaine and heroin, were sold by other residents, and that staff were supposed to check bags but did not. Staff interviews confirmed finding small clear baggies with white powdery substances in residents’ rooms and on bedside tables, sometimes inside narcotic boxes, and that some residents had tested positive for cocaine. One LPN acknowledged not documenting an incident where a resident dropped a baggie of suspected cocaine, despite recognizing the importance of maintaining a history of such events.

The facility also failed to ensure adequate supervision and monitoring for residents at risk for accidents unrelated to substance use. One resident fell inside the facility and sustained a left femur fracture, and another resident’s fall care plan was not updated and assessments were not followed after a fall, despite being identified as at risk. For residents with substance use disorders, care plans and assessments were incomplete or lacked specific monitoring interventions. For example, one resident’s care plan documented substance use and a positive opioid test with relapse but contained no interventions regarding monitoring. The facility’s own substance abuse protocol, as described by the substance abuse counselor, called for drug screening when substance use was suspected, room searches, incident reporting, care plan updates, and substance abuse assessments, but in at least one case the counselor acknowledged that a required substance abuse assessment was not completed after contraband was found. Staff also reported that residents were supposed to be monitored every 30 minutes, yet a resident with a known substance use history was found cold, rigid, and unresponsive in the morning, with other residents stating that staff did not perform rounds or announce themselves that shift.

Further, the report describes an incident where a newly admitted resident with a history of overdose and polysubstance abuse was found unresponsive shortly after a visitor left the room, with an unknown white powdered substance on the chest and additional baggies discovered under the sheets. The LPN on duty administered multiple doses of Narcan and called 911, and hospital records later confirmed polysubstance abuse with positive screens for fentanyl, heroin, and benzodiazepines. Another resident with severe cognitive impairment was found unresponsive with nasal flaring and no response to verbal or painful stimuli; Narcan was administered and the resident was transferred to the hospital, where records documented an opiate overdose despite a negative urine drug screen, with the physician noting that the naloxone response and history of opioid misuse suggested recent opioid exposure. The nurse practitioner stated that Narcan had been given to residents on multiple occasions due to the large population with illicit drug use history and that Narcan was used when nurses suspected opioid or illicit drug use. Staff across disciplines, including nursing, housekeeping, and social services, acknowledged that there were “a lot of overdoses,” that residents were “doing drugs,” and that some residents relapsed in the building, underscoring the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for residents at risk of overdose and falls.