Inspection·March 23, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide safe Gastrostomy tube (tube surgically inserted into the stomach through the abdomen) administration of medication according to standard of practice and physician order. This failure affected one of one resident (R50) reviewed for Gastrostomy tube medication administration on sample of 26. Findings include: R50's Physician Order Summary (POS) dated 2/22/23- 3/22/23, documents the following diagnoses: Personal history of traumatic brain injury, Gastrostomy status, Aphasia, Iron deficiency anemia, unspecified, Vitamin deficiency, unspecified, Epilepsy, unspecified, not intractable, without status epilepticus, Spastic hemiplegia affecting right dominant side, Encephalopathy, unspecified-static, Gastro-esophageal reflux disease without esophagitis, unspecified, Other muscle spasm, Nausea with vomiting, unspecified, and Dysphagia, unspecified. The same POS documents: Diet: NPO (nothing by mouth) with g-tube (Gastrostomy tube) feedings. Check g-tube placement via air bolus q shift. G-tube size 20FR (French). Check g-tube q shift if g-tube is dislodged or tube comes out, or tube is worn/cracked or clogged. Contact MD for further directions. Check g-tube residual every shift. If greater than 50 milliliters, hold feeding and notify physician. On 3/21/23 at 3:10 pm R50 was lying in bed. R50 did not respond verbally. Licensed Practical Nurse (LPN) and V3, Assistant Director of Nursing (ADON) entered R50's room. V11, LPN verified R50's G-tube placement by auscultation then residual. No residual noted at that time. V11 LPN removed the plunger of the syringe to administer the dissolved Baclofen and Senna medication and water flush. Before V11, LPN could administer the water flush or medication, approximately 20 cubic centimeters (cc) of feeding formula backed up, bubbling into the syringe. V11 inserted the syringe plunger. V11 used one hand and thumb, V11 held the syringe and pushed the syringe plunger as V11 applied mild to moderate pressure to advance the feeding formula that had backed up into the syringe. Once most of the feeding formula re-entered the G-tube, V11, LPN removed the plunger and added 30 cc water flush into the syringe with approximately five cc feeding formula still visible in the syringe. The g-tube was blocked and not accepting the 30 cc H20 flush. The flush sat inside the syringe. V11 re- inserted the syringe plunger. V11 used one hand and thumb and applied moderate pressure to the syringe plunger to advance the flush into R50's G-tube. The flush then moved slowly to gravity, into the g-tube. V11, LPN then removed the syringe plunger and added the medication dissolved in the 30 cc of water into the the syringe. The dissolved medication sat in the syringe and did not advance. V11, LPN again used one hand and thumb to apply moderate pressure to the syringe plunger to advance the 30 cc dissolved medication. The medication still did not advance into the g-tube. The g-tube remained clogged. V11 then used two hands, right hand holding the syringe and left palm of the hand to force the syringe plunger of the syringe. V11 removed the syringe plunger and approximately half of the dissolved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 2 of 3 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 146090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Inn of Danville 3222 Independence Drive Danville, IL 61832 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication moved slowly to gravity. V11 again re-inserted the syringe plunger and used two hands, the right hand holding the syringe and the left-hand palm to apply force to advance the plunger of the syringe. V11, LPN then attempted to administer the 20 cc water flush repeatedly pouring the water into the syringe, holding the syringe approximately 8 inches above the abdomen. The first two portions of the water flush advance slowly over approximately two minutes. The third and fourth met with resistance, and V11 repeatedly used two hands with more force to advance the plunger of the syringe. During the fourth portion of the water flush, V11's hands shook as she applied extreme force. V11's hands were visibly shaking as she held the syringe and applied extreme force to advance the water flush in the syringe. V11 removed the plunger and poured the remaining water into the syringe which advanced slowly into the g-tube. V11, LPN stated R50 has had a G-tube since a car accident when R50 was [AGE] years old. V11, LPN also stated I always try to do (R50's) g-tube (medications) by gravity, but if it's not going down, you gotta do what ya gotta do. On 3/21/23 at 3:35 pm V3, ADON It is standard of practice to stop administration of G-tube meds (medication) or feedings if there are problems with the flow. I saw the force she (V11, LPN) used. The forcing of the flush (water) and meds were not appropriate. If it was a nudge with the plunger, that is different than repeatedly applying a lot of pressure like (V11, LPN) did. On 3/22/23 at 8:15 am V2, Director of Nursing stated the following: (V11, LPN) should have never forced the plunger of the syringe, to advance the medication administration or flush (R50's) g-tube yesterday. I will be doing in-services, so this never happens again. The facility policy Tube Feeding G (Gastrostomy) and N/G Naso-Gastric) dated revised 3/3/22. documents the following: Purpose: 1. To provide a source of nourishment when oral feedings are neither possible nor desired due to resident condition. Objective: 1. To maintain the desired nutritional and fluid status of a resident. 2. To administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 3 of 3