Health inspection·July 10, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow their policy to report an allegation of abuse to the resident's representative for one (R1) of five residents reviewed for abuse in the sample list of six residents. Residents Affected - Few Findings include: The facility's Abuse Prohibition and Reporting policy dated as revised 11/28/19 documents The Administrator or designee shall notify the resident's representative of the alleged abuse. The facility's Final Report for an allegation of abuse dated 7/5/23 at 3:00 PM documents: On 07/05/2023 IDPH (Illinois Department of Public Health) surveyor entered the facility on an alleged complaint of mental abuse. Facility administrator immediately began an investigation into the allegation. Interview able residents were asked if they had ever heard or witnessed a staff member threaten themselves or another resident. Staff members were asked if they had ever witnessed or heard about any physical or verbal abuse towards residents from another staff member or if they had witnessed a staff member threaten a resident. Based upon investigation findings, the facility has determined the alleged complaint of mental abuse is unfounded. Facility will continue with ongoing staff education on abuse and resident rights. This serves as final report. This report does not document that R1 was involved in the alleged abuse or that R1's Family (V23) was notified of the alleged abuse. There is no documentation in R1's medical record that this allegation was reported to V23. On 7/5/23 at 12:51 PM V1 Administrator stated V1 has not received any abuse allegations involving staff threatening residents. At this time V1 was informed of an allegation that staff threatened a resident with the same first name as R1, to sit at the nurses station or the resident would be spanked. V1 stated V1 would consider that to be an allegation of abuse that would be reported and investigated. V1 confirmed the facility has no other residents besides R1 with the first name identified in the allegation. On 7/10/23 at 9:00 AM V2 Director of Nursing stated the final report of the 7/5/23 abuse allegation investigation was submitted on 7/7/23 to IDPH. At 9:17 AM V2 stated when we have an allegation of abuse involving a resident, we notify the resident's representative. V2 stated V2 thought this notification was documented on the final report form. V2 confirmed the facility's Final Report for the 7/5/23 abuse allegation does not document R1 as part of the allegation or that V23 was notified of the allegation. V2 stated V13 Social Services Director usually notifies the resident's representative of abuse allegations. On 7/10/23 at 9:23 AM V13 stated V13 notifies the resident's representative of abuse allegations. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 146090 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 07/10/2023 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)