Inspection·May 17, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have quarterly care plan meetings involving the resident/resident representative for three residents (R1, R2, R3) of six reviewed for care plan meetings in the sample list of eight. Findings include: 1.) R1's Minimum Data Set (MDS) log documents R1 admitted on [DATE]. Comprehensive MDSs were completed on 8/24/22, 11/16/22, and a significant change MDS was completed on 2/26/23. R1's Care Conference Report lists 6/1/22 as the only documented R1's Nursing Note dated 1/18/23, recorded by V2 Director of Nursing (DON), documents V14 (R1's Power of Attorney) was present for care meeting to discuss R1's overall status - wounds, pain, appetite, assistance with activities of daily living, wheelchair positioning, supplements/medications, code status, and the consideration of hospice services. This note does not document who participated in this meeting. There are no other documented care plan meetings in R1's medical record. 2.) R2's MDS log documents R2 admitted on [DATE]. Comprehensive MDSs were completed on 8/13/22, 10/24/22, 11/8/22 (significant change), and 2/8/23. There is no documentation that care plan meetings were held/offered with R2 or R2's family between 8/13/22 and 5/15/23. R2's Nursing Notes provided by V15 MDS/Care Plan Coordinator documents R2's family was notified on 10/31/22 of R2's overall status including wounds, appetite, activities of daily living, overall decline, and consideration of hospice services. This note does not document a care plan meeting was held or that members of the interdisciplinary team (besides V2 DON) were present during this review. 3.) R3's MDS log documents comprehensive MDSs were completed on 12/21/22, 3/7/23 (significant change), 3/17/23, and 4/7/23 (significant change). There is no documentation that care plan meetings were held/offered with R3 or R3's family following the completion of R3's MDS assessments. On 5/15/23 at 12:07 PM V15 stated care plan meetings are documented in a progress note or under the care plan conference section of the electronic medical record. At 3:18 PM V15 MDS/Care Plan Coordinator stated care plans are held yearly, unless otherwise requested by the resident/resident's family. At 3:44 PM V15 confirmed there was no documentation of care plan meetings in R3's medical record after October 2020. V15 stated V2 DON documented a weight note identifying weight loss and notification to R3's family, but the note does not document that a care plan meeting was held or who was present. V15 provided R2's care plan meeting documentation and confirmed care plan meetings were not completed quarterly. On 5/15/23 at 3:57 PM V1 Administrator stated the facility has not been conducting quarterly care plan meetings since that regulation was waived during the COVID-19 (Human Coronavirus) Pandemic. The facility's Care Plan Policy revised 6/1/22 documents the comprehensive care plan will be developed by the interdisciplinary team which includes the resident and the resident's representative. The resident and resident's representative will be invited to participate in the development and revision of the resident's care plan. The interdisciplinary team will review and revise the care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 2 of 5 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 05/17/2023 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 0657 after each comprehensive and quarterly Minimum Data Set. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 3 of 5 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 05/17/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to accurately account for controlled medications for two (R1, R3) of three residents reviewed for medications in the sample list of eight. Residents Affected - Few Findings include: 1.) R1's Physician's Order Summary dated 4/1/23 - 5/1/23 documents an order dated 2/23/23-4/9/23 for morphine concentrate (Schedule II Controlled Drug) 100 milligrams (mg)/5 milliliters (ml) give 0.25 ml as needed (with no specified time frames), an order dated 4/9/23-4/18/23 to give morphine 0.5 ml orally every 4 hours at 9:00 PM, 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, and 5:00 PM, and an order dated 4/16/23 to give 0.5 ml Morphine every hour as needed for breakthrough pain. R1's Individual Resident Narcotics Record with a start date of 3/25/23 documents the following: 0.25 ml of Morphine 100 mg/ml was dispensed on 4/7/23 at 9:00 AM and 4:00 PM. Morphine 0.5 ml was dispensed on 4/10/23 at 12:35 AM, 3:30 AM, 6:15 AM, 8:21 AM, 12:00 PM, 5:16 PM. This record does not document a dose was dispensed for the 4/11/23 5:00 PM dose or 4/13/23 5:00 AM dose. Morphine 0.5 ml was dispensed on 4/16/23 at 4:00 AM, 6:30 AM, 2:40 PM, and 4:20 PM. This log does not document that R1's 5:00 PM dose on 4/11/23 and 5:00 AM dose on 4/13/23 were dispensed, and these doses are signed out as administered on R1's Medication History Report. R1's Medication Administration History dated 4/1/23-4/24/23 does not match the entries listed above on R1's Narcotics Record. This Medication Administration History does not document Morphine was administered on 4/7/23, or on 4/16/23 at 4:00 AM, 6:30 AM, 2:40 PM, and 4:20 PM. R1's Morphine was administered on 4/10/23 at 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. R1's Morphine is signed out as administered on 4/11/23 at 5:00 PM and 4/13/23 at 5:00 AM. There are no documented morphine administrations for 4/16/23 at 6:30 AM, 2:40 PM, and 7:00 PM. On 5/15/23 at 3:07 PM V5 Assistant Director of Nursing stated medications should be administered during the designated time frame ordered or within an hour before/after a specific ordered time. V5 stated the nurses should be charting/signing out the medication on the Medication Administration Record (MAR) and the Narcotic Record at the time the medication is given. V5 confirmed the MAR and Narcotic Record entries should match. V5 reviewed R1's MAR and Morphine Narcotic Record and confirmed R1's MAR does not document Morphine was administered on 4/7/23 in accordance with the Narcotic Record, and the Narcotic Record does not document doses were dispensed on 4/11/23 at 5:00 PM and 4/13/23 at 5:00 AM as ordered. V5 confirmed R1's MAR and Narcotic Records do not match for entries noted on 4/10/23 and 4/16/23. 2.) R3's Medication Administration History dated 4/15/23-5/15/23 documents an order for morphine 100 mg/5 ml give 0.25 ml every 3 hours as needed. There are no recorded administrations between after 5/1/23 until 5/9/23. R3's Morphine 100 mg/5 ml Narcotic Record documents 0.25 ml was dispensed on 5/5/23 at 2:00 PM. On 5/15/23 at 3:07 PM V5 confirmed R3's Morphine dispensed on 5/5/23 at 2:00 PM is not recorded on R3's MAR. V5 stated the nurses get in a hurry and forget to sign out the medications. The facility's Medication Administration policy revised February 2004 documents medications are to be administered per the physician's order, and document on the MAR if a medication is not given and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 4 of 5 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 05/17/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the reason. This policy documents as needed medication administration and the response to the medication should be recorded on the MAR. Nurses initial the MAR to indicate the medication is administered. The facility's Controlled Drug Policy and Procedure revised May 2017 documents: The inventory of the controlled drugs must be recorded on the narcotic records and signed for correctness of count. If a discrepancy is found, check the resident's order sheets and chart to see if a narcotic has been administered and not recorded. Check previous recording on the control sheets for mistakes in arithmetic. If the discrepancy cannot be located an/or the count does not balance, report the matter to the Director of Nursing. Event ID: Facility ID: 146090 If continuation sheet Page 5 of 5