Health inspection·April 18, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to ensure a person-centered comprehensive care plan was developed with goals and interventions to address history of substance abuse for 1 (R1) of 3 residents reviewed for care planning in a sample of 3. Findings include: R1's face sheet documents an admission date of 01/18/24 with diagnosis including: Pulmonary Hypertension, Stimulant use, Unspecified Stimulant - induced Disorder, Other Stimulant Abuse in remission, Tobacco use, Major Depressive Disorder, lower back pain, and Intervertebral Disc Degeneration lumbar region. R1's undated care plan does not contain a Focus area with goal and interventions for the concern area of Stimulant use, Stimulant induced Disorder, or Stimulant Abuse in remission. R1's hospital summary of care dated 01/18/2024 documents a diagnosis of methamphetamine abuse. On 04/15/24 at 3:45 PM, R1 stated he has been a methamphetamine user and has been trying very hard to keep from using. On 04/16/24 at 10:10 AM, V2 (Director of Nursing/DON) stated R1 went out on a community pass on the 9th and signed out, he did not return to the facility until the next morning, the nurse on duty V13 (Registered Nurse/RN) notified V10 (Medical Doctor) that R1 was out overnight. V10 gave an order that when R1 returned to the facility he was to be drug tested. V2 stated V10 knows R1's history with drug use and that is why he ordered the drug screen. V2 stated she believes he discharged from the facility AMA (against medical advice) because how the situation with the drug test was handled and he didn't think it was fair because he called and tried to let the facility know he was having trouble getting back but no one answered the phone. V2 stated, R1 was not told in advance that he would have to drug screen if he did not make it back to the facility before midnight or acted under the influence to her knowledge. On 04/16/24 at 3:45 PM, V10 (Medical Doctor) stated he ordered the drug screening for R1 upon return to the facility due to R1's history of drug use. R1's Physician Order Sheet dated 04/01/24 documents an order dated 04/10/24 stating: Upon arrival to facility do a urine screen: Hold pain meds (medications) until MD (medical doctor) notified of results. Page 1 of 2 146021 146021 04/18/2024 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/16/24 at 3:30 PM, V6 (Minimum Data Set Coordinator/Care Plan Coordinator) stated she did not know why they did not have anything in R1's care plan relating to R1's history of substance abuse problems. V6 stated they did not have anything care planned for drug screening or community passes, and he did not have a section relating to substance abuse. V6 stated they did not have anything in place to monitor R1 especially when he returned from community passes or if he returned late from a community pass. On 04/16/24 at 12:15 PM, V2 (DON) stated they did not have anything in place on R1's care plan in relation to his past history of drug use including anything with community passes or drug screening and they should have. On 04/16/24 at 1:29 PM, V8 (Licensed Practical Nurse) stated R1 returned to the facility from a community pass when she was on shift. V8 stated R1 came in and was going down the hall to his room and was talking about getting a flat tire and being stranded in the country. V13 (RN) told her there was an order for R1 to drug screen when he returned, so she went to his room and gave him the cup. He was not happy about having to drug screen. On 04/18/24 at 8:58 AM, V1 (Administrator) stated they do not have a care plan policy. 146021 Page 2 of 2