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. Page 1 of 4 146090 146090 07/10/2023 Hawthorne Inn of Danville 3222 Independence Drive Danville, IL 61832

F 0607 V13 stated V13 was not aware that R1 was involved in an abuse allegation and V13 did not notify V23 of the allegation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146090 Page 2 of 4 146090 07/10/2023 Hawthorne Inn of Danville 3222 Independence Drive Danville, IL 61832

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medications were available to be administered as ordered for four (R6, R2, R3, R4) reviewed for medications in the sample list of six. Findings include: 1.) R6's Face Sheet dated 7/10/23 documents R6 has diagnoses of Pneumonia, Atrial Fibrillation, Muscle Spasms, and history of Transient Ischemic Attack and Cerebral Infarction without residual deficits. R6's Physician's Order with a start date of 7/4/23 and stop date of 7/6/23 documents to administer Augmentin (antibiotic) 875 milligrams (mg) - 125 mg one tablet by mouth twice daily. R6's Physician's Order with a start date of 7/4/23 and stop date of 7/7/23 documents to administer Azithromycin (antibiotic) 500 mg one tablet by mouth once daily. R6's Physician's Orders dated 7/3/23 documents to administer Baclofen (muscle relaxant) 10 mg by mouth three times daily and administer Warfarin (anticoagulant) 2.5 mg one tablet by mouth once daily. R6's Medication Administration Record (MAR) dated 7/1/23-7/10/23 documents the following: Augmentin and Azithromycin were not administered as ordered on the morning of 7/4/23. Baclofen was not administered as ordered on 7/4/23 and 7/5/23. Warfarin was not administered as ordered on 7/4/23. The reason for why these medications were not administered is documented as the medications were not available. R6's Nursing Notes document R6 admitted to the facility on [DATE] at 4:45 PM. R6's Nursing Note dated 7/05/2023 3:26 PM documents attempts were made to contact R6's physician to report that Baclofen has not come in yet. There is no documentation that the pharmacy was contacted to obtain R6's Augmentin, Azithromycin, Baclofen, or Warfarin, or that the physician was notified of the missed doses of medications. On 7/5/23 at 3:05 PM V19 Licensed Practical Nurse stated R6 admitted to the facility on [DATE] and there were issues with getting R6's medications from pharmacy due to the holiday (7/4/23.) V19 stated R6 does not have a supply of Baclofen to administer. V19 stated normally we contact the pharmacy to order medications, but yesterday was a holiday. V19 stated R6's medications should be arriving today from the pharmacy. 2.) R2's Physician's Order dated 8/28/22 documents to administer Combigan 0.2-0.5 % eye drops, one drop into each eye twice daily. R2's MAR dated 6/7/23-7/5/23 documents Combigan was not administered as ordered 6/19/23-6/22/23 due to the medication being unavailable. There is no documentation in R6's Nursing Notes that the pharmacy was notified to obtain Combigan or that the physician was notified of the missed doses of medication. 3.) R3's Physician's Order dated 1/30/23 documents to administer Lutein 20 mg one capsule once daily. 146090 Page 3 of 4 146090 07/10/2023 Hawthorne Inn of Danville 3222 Independence Drive Danville, IL 61832

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R3's MAR dated 6/7/23-7/5/23 documents Lutein was not administered on 06/10/2023 and on 6/14/23 due to the medication being unavailable. There is no documentation in R3's nursing notes that the pharmacy was contacted to obtain R3's Lutein. 4.) R4's Physician's Order dated 2/28/23 documents to administer Otezla (treats psoriasis) 30 mg one tablet twice daily. R4's MAR dated 6/7/23-7/5/23 documents Otezla was not available and not administered on 06/09/2023 evening dose, 6/13/23 morning dose, and 6/25/23 evening dose. There is no documentation in R4's Nursing Notes that R4's family was contacted to obtain Otezla or that R4's physician was notified of the missed doses of medications. On 7/10/23 at 10:08 AM V2 Director of Nursing stated the facility has an after-hours pharmacy that is responsible for delivering medications after normal business hours and on holidays. V2 stated the nurses have been instructed to foresee upcoming holidays and to get medication orders into the pharmacy. If medications are unavailable the nurses should check the (convenience medication box), and if it is out of the medication needed then the nurses should contact the pharmacy to refill the box. V2 stated if the resident is out of a medication the nurses should contact the pharmacy to reorder and notify the physician of the missed doses of medications. V2 stated notification is documented in the nursing notes. V2 stated if the facility has a new admission and it's a holiday, then V2 expects the nurses to follow the same process. V2 stated R4's family provides R4's Otezla and the nurses should have notified R4's family to bring in a supply. At 10:30 AM V2 provided a copy of the facility's Medication Administration policy. V2 stated the policy documents to record when a medication is not given. V2 confirmed the policy does not document the steps to take when medications are not available. V2 stated the facility does not have a policy for reordering/obtaining medications from the pharmacy. V2 provided a copy of the list of medications located in the facility's (convenience medication box), and confirmed Azithromycin, Augmentin, and Warfarin are included in the list. The facility's (convenience medication box) Inventory List documents the box contains Azithromycin 250 mg two tablets, Augmentin 875-125 mg eight tablets, and Warfarin 2.5 mg eight tablets. The facility's Medication Administration using eMAR (Electronic Medication Administration Record) dated as November 2011 documents to record the reason for not administering a medication. This policy does not document the steps to take when medications are not available. 146090 Page 4 of 4