Inspection·April 17, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely transmit a Minimum Data Set (MDS) assessment for one (R35) of 18 residents reviewed for MDS assessments in the sample list of 36. Residents Affected - Few Findings include: The facility's MDS Completion policy dated 6/1/22 documents the MDS Coordinator will ensure completion of the MDS assessments and will transmit MDS assessments at least weekly. This policy documents comprehensive assessments will be transmitted within 14 days of the Care Plan completion date; and Prospective Payment System and Quarterly assessments will be transmitted within 14 days of the completion date. R35's electronic medical record MDS listing documents R35's Annual MDS dated [DATE] was completed, but not submitted. On 4/16/24 at 11:26 AM V10 MDS/Care Plan Coordinator stated R35's January 2024 MDS has not been submitted yet since V10 was not familiar with how to complete the CAA (Care Area Assessment) section of the MDS. V10 stated there is a 14 day window to complete annual MDS assessments. V10 confirmed V10's MDS will be submitted late. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 2 of 17 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 04/17/2024 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 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 observation, interview and record review the facility failed to ensure residents received the recommended/ordered amount of Enteral feeding for two of two residents (R53, R11) reviewed for Enteral feedings in the sample list of 36. Findings include: The facility's Tube Feeding (G and N/G) (Gastrostomy and Nasogastric) policy with a revised date of 3/3/22 documents, Objectives: 1. To maintain the desired nutritional and fluid status of a resident. Procedure: 1. M.D. (Medical Doctor) will order type of feeding supplement, duration/rate of feeding, frequency, and amounts of flushing. Order must include caloric content, as well as volume. Documentation: 1. Date/time of feeding. 2. What was administered, flow rate, and duration of feeding. 3. Any complications or new occurrences before, during, or after procedure. 4. Licensed staff completing the procedure. 5. Maintain accurate documentation of Intake and Output for every shift and for every 24 hours. 1.) R53's Care Plan dated 2/23/24 documents diagnoses including Personal History of Traumatic Brain Injury at age [AGE], Aphasia, Spastic Hemiplegia Affecting Right Dominant Side, Encephalopathy, Gastro-Esophageal Reflux Disease and Dysphagia. R53's Physician Order Report dated 3/16/24 through 4/16/24 documents orders with a start date of 2/5/24 to hang a new tube feeding bag of Fibersource HN (high nitrogen) every 24 hours, and to write residents name, room number, rate, date, and solution on feeding bag once a day 3:00 PM. This Order Sheet documents an order for Fibersource HN 1.2 kcals/ml (kilocalorie/milliliter) at 105 ml/hour for 18 hours and flush with 250 ml water three times a day. This Order Sheet documents This new schedule will provide 1890 ml volume of formula. Special Instructions: Disconnect feeding at 7am (and) connect the feeding at 1pm for diagnosis of Dysphagia. On 4/15/24 at 9:45 AM, R53 was not in R53's room, but the tube feeding pump was in the room with a partially full bag of Fibersource HN hanging dated 4/15/24 at 3:00 AM and 105 ml/hr written on the bag. On 4/15/24 at 1:35 PM, R53 was lying in bed and the G-tube (Gastrostomy tube) was not hooked up and the pump was not turned on. On 4/15/24 at 2:02 PM, R53 was lying in bed and the G-tube was not hooked up and the pump was not turned on. On 4/15/24 at 2:24 PM, R53 was lying in bed and the G-tube was not hooked up and the pump was not turned on. On 4/15/24 at 2:59 PM, R53 was lying in bed and the G-tube was just hooked up and started, it had administered 2 mls (milliliters) of feeding. On 4/15/24 at 2:56 PM, V7 Registered Nurse stated V7 forgot to start it and just realized it was supposed to have been started. V7 stated that V7 will notify the Physician. On 4/17/24 at 9:00 AM, V2 Director of Nursing provided a 14 day administration history for R53's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 3 of 17 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 04/17/2024 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 Fibersource HN. Level of Harm - Minimal harm or potential for actual harm R53's ordered amount of feeding per day is supposed to be 1890 ml of Fibersource HN. R53's 14 day administration history documents from 4/1/24 through 4/16/24, R53 did not receive the ordered amount on 12 of those 16 days. The totals for the days that R53 was not administered enough feeding are as follows: Residents Affected - Few 4/2/24 total 1544 mls and 346 mls short 4/3/24 total 1529 mls and 361 mls short 4/4/24 total 1782 mls and 108 mls short 4/5/24 total 1627 mls and 263 mls short 4/6/24 total 1594 mls and 296 mls short 4/9/24 total 1617 mls and 273 mls short 4/10/24 total 1787 mls and 103 mls short 4/11/24 total 1617 mls and 273 mls short 4/12/24 total 1804 mls and 86 mls short 4/13/24 total 1884 mls and 6 mls short 4/14/24 total 1753 mls and 137 mls short 4/15/24 total 1568 mls and 322 mls short R53's weights for the last six months fluctuated down and then back up approximately three pounds. R53's medical record documents R53's weight on 11/2/23 was 160.9 pounds, on 12/5/23 it was 161 pounds, on 1/3/24 it was 161.4 pounds, on 2/6/24 it was 159.6 pounds, on 3/13/24 it was 153 pounds, on 4/3/24 it was 158.8 pounds and R53's weight on 4/16/24 was 161.6 pounds. There was no documented significant weight loss. On 4/15/24, R53 did not appear dehydrated or malnourished. 2.) R11's Physician Order Report dated 4/1/24 through 4/17/24 documents diagnoses including Multiple Sclerosis and Dysphagia. This Order Report documents an order to connect the G-tube at 4:00 PM and turn off the G-tube at 12:00 PM every day with a start date of 11/3/23. This Order Report documents an order to hang a new tube feeding bag of Fibersource every 24 hours and write the residents name, room number, rate, date and solution on the feeding bag once a day at 4:00 PM with a start date of 2/5/24. This Order Report documents an order for Fibersource at 95 ml/hr for 20 hours which will provide 1900 ml volume of formula for diagnosis of Dysphagia. On 4/15/24 at 10:02 AM, R11 was in bed with the Fibersource running at 95 ml/hr with 460 mls in since the pump was reset. R11 does not speak but shakes his head in response to questions and will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 4 of 17 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 04/17/2024 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 slowly type on the computer to communicate. R11 typed that he had a feeding pump for a while and shook his head no, when asked if there were any concerns regarding the feedings. R11 did not appear dehydrated or malnourished. On 4/17/24 at 8:36 AM, V5 Registered Nurse stated that they document intake every shift and clear the pump at that time. R11's ordered feeding amount is 1900 mls of Fibersource. R11's 14 day administration history documents from 4/1/24 to 4/16/24 R11 did not receive the recommended/ordered amount of feeding on 13 of the 16 days reviewed. The totals for the days that R11 was not administered enough feeding are as follows: 4/1/24 total 1528 mls and 372 mls short 4/2/24 total 1630 mls and 270 mls short 4/3/24 total 1883 mls and 17 mls short 4/4/24 total 1651 mls and 249 mls short 4/5/24 total 1605 mls and 295 mls short 4/6/24 total 1296 mls and 604 mls short 4/7/24 total 1788 mls and 112 mls short 4/8/24 total 1547 mls and 353 mls short 4/9/24 total 1812 mls and 88 mls short 4/10/24 total 1781 mls and 119 mls short 4/11/24 total 1806 mls and 94 mls short 4/15/24 total 1490 mls and 410 mls short 4/16/24 total 1757 mls and 143 mls short R11's weights for the last six months fluctuated down then up again. R11's weight on 11/1/23 was 185 pounds, on 12/6/23 it was 188.8 pounds, on 1/3/24 it was 188 pounds, on 2/6/24 it was 184.1 pounds, on 3/5/24 it was 190.1 pounds and then on 4/3/24 R11's weight was 190.4 pounds. R11 did not have any significant weight loss or gain in the last six months. On 4/17/24 at 11:03 AM, V2 Director of Nursing confirmed that R53 and R11 were not getting the ordered amount of feeding via their G-tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 5 of 17 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 04/17/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to obtain Physician's Orders for oxygen administration and failed to care plan for the use of oxygen for one of two residents (R32) reviewed for oxygen use in the sample list of 36. Residents Affected - Few Findings include: The facility's Oxygen Therapy & (and) Safety policy with a revised date of 4/9/20 documents, Purpose: To provide a source of oxygen to persons experiencing an insufficient supply of same and to address the use and storage of oxygen and oxygen equipment. Oxygen Therapy a. M.D. (Medical Doctor) order will provide: when to use, how often, liter flow, and whether to use cannula or mask. Address use of oxygen in Care Plan. R32's Physician Order Report dated 3/16/24 through 4/16/24 documents diagnoses including Alzheimer's Disease with Late Onset, Anxiety Disorder, Acute Upper Respiratory Infection, Cough and Wheezing. This Order Report documents an order to change oxygen tubing and humidification bottle every week but there is no order for the oxygen administration, and no order to designate the amount of liter flow or the type of administration, whether it was by a nasal cannula or by a mask. On 4/15/24 at 9:33 AM, R32 was in bed with the oxygen on via nasal cannula with visitors in the room and the setting was not in view. The oxygen concentrator was plugged in and heard running. R32's Care Plan dated 4/4/24 does not document the use of oxygen or interventions for the oxygen use. On 4/17/24 at 11:03 AM, V2, Director of Nursing stated that nurses can start oxygen on a resident as a nursing measure then they would obtain an order from the doctor. V2 confirmed there was no order for oxygen administration for R32 in R32's electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 6 of 17 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 04/17/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately and routinely assess side rail use per the facility's policy, obtain consent for side rail use, document alternative interventions attempted prior to use, and care plan for side rails for two (R9, R59) of two residents reviewed for siderails in the sample list of 36. Findings include: The facility's Side Rails policy dated 11/28/17 documents: It is the policy of the facility to ensure that side rails are not used unless an assessment to determine risk has been completed and it is determined that the side rails do not pose a danger to the resident. The facility will use appropriate alternatives prior to installing a side or bed rail. An assessment will be completed by licensed staff prior to the use of side rails. If the resident is assessed and it is determined that the resident would benefit from the use of side rails to promote independence, reassessment will occur at least every 90 days. Risk of benefits of side rail use will be reviewed and a signed consent will be obtained from either the resident, resident representative or guardian for the use of side rails if side rails are determined to be appropriate and necessary for the resident. 1.) On 4/15/24 at 9:30 AM there was a half length siderail in the upright position on one side of R9's bed, and R9 was sitting on this side of the bed. On 4/16/24 at 9:27 AM the half siderail remained in the upright position on R9's bed. R9 was sitting in the recliner in R9's room. R9 stated R9 does not really use the railing. R9 stated I suppose it is there if I need something to hold onto to get in/out of bed. R9's Minimum Data Set (MDS) dated [DATE] documents R9 has moderate cognitive impairment and is independent with rolling side to side and when moving to sitting/lying/standing positions. R9's Care Plan dated 4/12/24 documents R9 has Dementia and does not document side rail use. R9's May 2024 Medication Administration Record (MAR) documents R9 received Gabapentin (anticonvulsant) 300 milligrams (mg) daily, Isosorbide Dinitrate (antihypertensive) 10 mg twice daily, Lisinopril (antihypertensive) 10 mg twice daily, Lorazepam (antianxiety) 0.5 mg once daily as needed, Melatonin (sleep supplement) 3 mg daily, and Plavix (antiplatelet) 75 mg daily. R9's Side Rail/Device Assessment/Consent dated 5/11/23 (R9's admission date) is incomplete and inaccurate, and there are no other documented side rail assessments in R9's medical record. The sections to determine if R9 is immobile and if R9 has postural hypotension is blank/incomplete. This assessment documents that R9 does not have poor safety awareness, R9 does not have difficulty with bed mobility or when moving to sit on the side of the bed, R9 has not expressed a desire to use side rails, and no suitable alternative interventions have been attempted. This assessment inaccurately documents R9 does not use any medications that require increased safety precautions which includes antihypertensives, anticonvulsants, benzodiazepines, non-benzodiazepine sedatives, and antithrombotics. This form does not document if side rails were used during the assessment or consent was obtained for side rail use as indicated on the form. On 4/16/24 at 12:30 PM V13 Certified Nursing Assistant (CNA) stated V13 was unsure how long the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 7 of 17 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 04/17/2024 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 0700 siderail had been on R9's bed, and the siderail is used when R9 is in bed. Level of Harm - Minimal harm or potential for actual harm On 4/16/24 at 12:39 PM V12 CNA stated R9 probably uses the siderail to transfer into bed, and R9 does a lot for herself including making her bed and transferring independently. Residents Affected - Few 2.) On 4/15/24 at 9:15 AM and 4/16/25 at 9:25 AM R59 was lying in bed asleep and there were half side rails in the upright position on both sides of the bed. On 4/16/24 at 12:15 PM R59 stated R59 uses the siderails to assist with turning in bed and they prevent R59 from falling out of bed. R59's MDS dated [DATE] documents R59 has moderate cognitive impairment, requires substantial/maximal assistance for rolling and when moving from lying to sitting on the side of the bed. This MDS documents R59 is dependent on staff when moving from sitting to lying and sitting to standing. R59's Care Plan dated 4/12/24 documents R59 has Dementia, and transfers with a full mechanical lift. This care plan does not document side rail use. R59's MAR dated 4/1/24-4/16/24 documents the following medications since R59 admitted in April 2023: Amlodipine (antihypertensive) 10 mg daily, Jardiance (hypoglycemic) 10 mg daily, Lexapro (antidepressant) 5 mg daily, Metformin (hypoglycemic) 500 mg twice daily, and Metoprolol Succinate (antihypertensive) Extended Release 50 mg daily. R59's Side Rail/Device Assessment/Consent dated 4/3/23 is incomplete and inaccurate, and there are no other documented assessments in R59's medical record. This assessment documents R59 does not have altered safety awareness, R59 does not have difficulty with bed mobility or moving to sit on the side of the bed, R59 requested side rail use and to be released when R59 is asleep. On 4/16/24 at 12:41 PM V2 Director of Nursing stated side rail assessments are done for all residents upon admission regardless if side rails are used, and the assessment is completed by the floor nurse. V2 stated if the resident has a change in condition or request side rail use after admission then a new assessment should be completed, otherwise side rail assessments are completed annually by the MDS Coordinator. V2 stated when completing the side rail assessment the floor nurse should observe the resident's use of the side rail, review history reports including medication use, and document prior alternative interventions used. V2 stated residents with dementia have altered safety awareness. V2 stated the consent for use is documented on the assessment and signed by the resident's Power of Attorney if the resident has cognitive impairment; and side rail use is documented on the resident's care plan. V2 confirmed R9's and R59's side rail assessments are incomplete/inaccurate, and R9 does not have a documented signed consent for side rail use. V2 stated V2 did not realize that R9 used a side rail and based on that assessment (R9's) I'm not sure why it (side rail) is up (in use). On 4/16/24 at 1:10 PM V10 MDS/Care Plan Coordinator stated side rail assessments are completed upon admission and then annually with the MDS schedule. V10 stated R59 has not had a side rail assessment after the initial admission assessment on 4/3/23. V10 stated typically side rail use is listed on the resident's care plan under the resident care section. V10 confirmed R9's and R59's care plans do not include side rail use. On 4/16/24 at 2:00 PM V2 stated V2 did not realize that the facility's side rail policy documents to re-evaluate for use every 90 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 8 of 17 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 04/17/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R178's Face Sheet dated 4/17/2024 documents R178 admitted to the facility on [DATE]. R178's medication order sheet (4/17/2024) documents R178 began receiving the psychotropic anxiety medication alprazolam (0.5 milligrams by mouth, twice daily as-needed) on 4/16/2024. The same record documents R178 began receiving the psychotropic depression medication venlafaxine (37.5 milligrams by mouth, twice daily) on 4/11/2024. R178's electronic medical record (undated) does not document R178's alprazolam mediation order is limited, as required, to a 14 day time period before requiring medical review for renewal. The same record does not document any consent for treatment for R178's psychotropic medications. On 4/17/2024 at 2:12PM, V2 (Director of Nursing) reported I do not see where they (facility staff) did consents (for R178's psychotropic medications) and V2 also reported R178's as-needed alprazolam medication order should have been limited to a 14 day period.Based on interview and record review the facility failed to complete quarterly psychotropic mediation assessments, failed to identify/document/care plan specific targeted behaviors and nonpharmacological interventions, failed to include a duration for a PRN (as needed) psychotropic medication order, failed to failed to obtain/document consent for psychotropic medication use, and failed to rule out underlying causes of behaviors prior to initiating psychotropic medications for three (R58, R78, R36) of five residents reviewed for unnecessary medications in the sample list of 36. Findings include: The facility's Psychopharmacologic Drug Usage Procedure dated 10/18/17 documents psychotropic medication use will be evaluated initially and at least every 90 days and include the rationale for continuing the medication. This policy documents PRN psychotropic medications will be limited to 14 days unless otherwise ordered by the physician with a documented rationale to extend beyond the 14 day timeframe, and the duration of the order will be indicated. This policy documents psychotropic medication consent forms will be given to the resident and/or resident representative and will include medication name, reason for use, possible risks/side effects, and benefits of use. This policy documents behaviors that warrant the use of psychotropic medications will be documented routinely and the care plan will include nonpharmacological interventions/alternatives of behavior management. 1.) R58's Minimum Data Set (MDS) dated [DATE] documents R58 has moderate cognitive impairment and had delusions and verbal behaviors towards others during the seven day look back period. R58's physician order dated 3/21/24 documents to administer Seroquel (antipsychotic) 100 milligrams (mg) by mouth daily. R58's August 2023 Medication Administration Record documents Seroquel was increased from 100 mg daily to 150 mg daily on 8/8/23. R58's Nursing Notes document: On 7/26/2023 at 4:05 PM R58 had increased behaviors/agitation claiming that items were stolen from R58's room, and R58's family was called. On 8/7/23 R58 had delusions that R58's spouse was having an affair, R58 was angry with R58's family, and the physician was notified. There is no documentation what nonpharmacological interventions were used and unsuccessful in managing R58's behaviors prior to contacting the physician. On 8/16/2023 at 12:48 PM R58 alleged that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 9 of 17 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 04/17/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R58's belongings were stolen, staff told R58 they would watch R58's belongings and report R58's concerns. R58 said R58 will call the police if something isn't done. On 8/20/2023 at 3:45 PM R58 alleged that R58's hearing batteries were stolen and refused to allow staff to lock the batteries in the medication room. R58 also reported missing two sweaters. On 3/03/2024 at 5:39 PM R58 was upset that another unidentified resident had company sitting in R58's seat at the table, R58 wanted R58's family called to pick R58 up, and it was R58's spouse's fault that R58 wants a divorce. R58 was redirected with some effectiveness. On 3/11/2024 at 9:54 AM R58's behaviors are usually easily redirected if R58 is allowed to say what R58 wants and then allowed to return to R58's room to calm down. On 3/12/2024 at 9:27 PM R58 demanded R58's family be contacted to pick R58 up or R58 would call the police. R58 was redirected with no further signs of distress. On 3/19/2024 at 1:29 PM R58 came to the nurse's station upset that R58's family never visits. Staff offered to take R58 to see R58's spouse and R58 declined stating R58 had enough of R58's spouse who wants nothing to do with R58, and R58 then paced the hallway and ignored anyone who attempted to speak to R58. On 3/25/2024 at 10:34 AM R58 was upset with R58's family and stated R58's family has taken everything from R58. R58 stated R58 was going to get out of the facility and go home and R58 brought an empty lotion bottle to the nurse's station and insisted that someone had been in R58's room and used R58's lotion. Staff gave R58 more lotion and R58 returned to R58's room. On 3/26/2024 at 1:05 PM R58 wanted to call R58's family to come and get R58 and R58 stated R58 was tired of people going into R58's room and going through R58's clothing; and it was explained that R58's family was at work and a message was left. R58's Psychopharmacological assessment dated [DATE] documents an increase in R58's Seroquel to 150 mg daily due to negative and loud verbalizations towards staff and R58's family and R58 has Alzheimer's Disease and Delusional Disorder. This assessment does not document nonpharmacological interventions that were used and ineffective prior to the increase in Seroquel. There are no documented psychotropic medication assessments in R58's medical record after 8/7/23 until 2/9/24. R58's Psychopharmacological assessment dated [DATE] documents R58 has delusional disorder, paranoia, and agitation; R58 receives Seroquel 125 mg daily; R58 refuses care, has delusions and has anxiousness/agitation; and nonpharmacological interventions include assisting with activities of interest, position change, environmental adjustment, offer food/drink, return to room, offer toileting or other care needs. These assessments do not identify R58's specific behaviors of delusions/behaviors that are associated with R58's spouse/family or that items are being taken from R58's room. R58's Care Plan dated 4/1/24 documents R58 has delusional disorder, receives psychotropic medication, has verbal behaviors, believes people take R58's belongings and when items are found in R58's room, and R58 tells others to stay out of R58's room. This care plan documents interventions to allow R58 to discuss delusions and plans, invite R58 to attend activities of interest and share stories about R58's life and family, allow R58 to process care before starting, when R58 is agitated ask R58 to move to a quiet area and engage in reminiscing, assist R58 to watch television, assist with making telephone calls to family and assist R58 in visiting R58's spouse. This care plan does not identify R58's behaviors of wanting to go home or behaviors/delusions related to R58's spouse. R58's March/April 2024 and June 2023-August 2023 Behavior Intervention Tracking Form documents verbal behaviors towards others/staff as R58's targeted behavior and includes interventions to provide reassurance before starting care so R58 knows staff are there to help R58, remind R58 staff will take R58 to see R58's spouse on Thursdays, leave R58's room to allow R58 to calm down, and invite to activities and discussions of R58's interests. These forms document R58's verbal behaviors occurred only once during these time frames and the forms do not document R58's other behaviors related to items being stolen, wanting to go home, or R58's spouse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 10 of 17 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 04/17/2024 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 0758 On 4/16/24 at 12:34 PM V13 Certified Nursing Assistant (CNA) stated R58 does not have any behaviors. Level of Harm - Minimal harm or potential for actual harm On 4/17/24 at 9:12 AM V2 Director of Nursing stated R58 was sent to a psychiatric hospital in March 2023 after getting in disagreements with R58's spouse and threatening to beat R58's spouse due to delusions that R58's spouse was cheating on R58. V2 stated R58's spouse was moved from R58's unit and was supervised visits were scheduled. V2 stated the nurses document behaviors in the nursing notes, the CNAs document behaviors and interventions on the behavior tracking reports, and the resident's care plan should include specific behaviors and interventions which staff should be following. V2 confirmed verbal behaviors towards staff/others is the only identified behavior on R58's behavior tracking forms. V2 stated we were told by corporate staff to complete a psychotropic medication observation/assessment annually and then document psychotropic medication reviews in the progress notes. V2 stated V2 discovered last night that psychotropic observation/assessments should be done on a quarterly basis after V2 reviewed the facility's policy. V2 confirmed R58 did not have a psychotropic medication assessment after 8/7/23 until 2/9/24. Residents Affected - Few 3.) R36's electronic medical record documenrts R36 was admitted to the facility on [DATE] for therapy following a surgical hip fracture repair. R36's Hospital discharge date d 7/10/23 documents R36 diagnoses of Alzheimer's late onset, acute post procedural pain, and cognitive communication deficit, as well as lists the following medications prescribed included two antidepressants (Celexa 20 mg (milligrams) daily and Trazadone 75 mg daily at night). There were no other psychotropic medications or psychiatric diagnosis listed. R36's admission mood and behavioral assessment dated [DATE] documents dementia/Alzheimer's disease with no behaviors and indicates there are no other behavioral or psychiatric issues. R36's Nursing Notes document the following: On 7/13/23 R36 was started on Macrobid (antibiotic) for a urinary tract infection. On 7/17/23, the notes document R36 was aggressive with staff during perineal care, and later that shift refused perineal care. On 7/22/23 R36 fell, was transferred to the hospital, and did not sustain any injuries. On 8/2/23 R36 was very resistant to perineal/incontinence care. On 8/4/23 R36 was combative during perineal care. On 8/8/23 the nurse received a call from R36's family member, whom is not the POA (Power of Attorney), requesting that R36 be started on Risperidone (antipsychotic) for behaviors. On 8/9/23 R36 was seen by the nurse practitioner and new orders were received for Risperidone 0.5 mg by mouth twice daily and a new diagnosis of delusional disorder. There is no documentation in R36's medical record that behavioral tracking was completed in July and August 2023, prior to 8/23/23. R36's Behavior Tracking started on 8/23/23 documents behaviors of aggression both physical and verbal. There is no tracking for delusional thoughts/behaviors or nonpharmacological interventions that were used to respond to these behaviors. R36's Psychopharmacologic assessment dated [DATE] documents does not identify delusional behaviors or statements. There is no documented episodes of delusional behavior in R36's observations/assessments or nursing notes prior to the Risperidone order and delusional disorder diagnosis dated 8/9/2023. R36's Medication Administration Records (MAR) dated 7/10/23-8/09/23 show R36 was given narcotic pain medication ordered PRN (as needed) only once on 7/24/23. These MARs also document R36 received Tylenol 650 mg on seven separate occasions without follow up for pain relief effectiveness. R36 did not receive pain medication on the dates the nursing notes document behaviors during cares. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 11 of 17 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 04/17/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm On 4/17/24 at 9:45AM, V2 stated that V2 believed R36 had a previous history of delusions prior to admission to the facility. V2 acknowledged that behavior tracking as well as nonpharmacological interventions are to be initiated prior to starting any psychotropic medication. V2 also acknowledged that root cause of behaviors should be investigated. V2 was asked about R36's pain control, V2 stated V2 believed R36 was on scheduled pain medication. V2 requested time to investigate and follow up. Residents Affected - Few On 4/17/24 at 11:00AM, V2 stated R36 was not on routine pain medication but the documentation showed R36 reported no pain. V2 acknowledged that documentation showed R36 only had behaviors during perineal care when R36's surgical side was involved. V2 acknowledged that R36 came into facility with a diagnosis of acute post procedural pain and a cognitive communication diagnosis and that R36 could have been unable to express R36's pain verbally. V2 stated V2 spoke with R36's family member and that R36 had been seen by a neuroscience physician prior to admission, at which time they discussed starting Risperidone but never did. When V2 was asked if R36 displayed any behaviors during stay prior to Risperidone ordered on 8/9/23, V2 denied any knowledge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 12 of 17 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 04/17/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 74 residents in the facility. Residents Affected - Many Findings include: On 4/15/2024 at 10:28AM, V16 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V16 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V16 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V16 reported the facility dietician only provides services for the facility one day per month. At this time, V16 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. Throughout the duration of the survey from 4/15/2024-4/17/2024, the facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label TCS (time/temperature control for safety) food, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food storage equipment. The facility Long-Term Care Facility Application for Medicare and Medicaid (4/15/2024) documents 74 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 13 of 17 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 04/17/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label TCS (time/temperature control for safety) food, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food storage equipment. These failures have the potential to affect all 74 residents residing in the facility. Findings include: 1. On 4/15/2024 at 10:43AM, the kitchen walk-in freezer evaporator cooling unit was leaking condensate into a plastic bin located below the cooling unit on a wire storage shelf. The leak resulted in large accumulations of ice forming inside of the bin and overflowing onto shelving beneath the bin. Numerous boxes of food items were stored directly beneath the leaking cooling unit. A fully-opened cardboard box of cookies was stored immediately below the overflowing bin, directly exposing the cookies to the leaked condensate. Frozen condensate drips were present on the box interior. On 4/17/2024 at 11:14AM, V16 (Dietary Manager) observed the above leak and reported the leak had been present for three years. 2. On 4/15/2024 at 10:44AM, an ice scoop was stored in a plastic caddy adjacent to the facility's main icemaker near the kitchen. The tip of the scoop was resting in stagnant water containing gray and green colored debris resembling biological growth. The caddy did not have any drain holes to prevent the accumulation of water after scoop use and did not have any riser present to prevent the tip of the scoop from resting into any accumulated water. On 4/17/2024 at 11:07AM, the ice scoop remained as above. V16 was present and stated the tip of the scoop being immersed into the contaminated water was not acceptable. 3. On 4/15/2024 at 10:36AM, an opened and partially used three-pound package of cream cheese was located in the kitchen reach-in cooler. The package was not labeled to indicate the date or time opened or a use-by date for dietary staff to know when the cream cheese must be used or discarded for safety. On 4/17/2024 at 11:14AM, the unlabeled package of cream cheese remained as above in the kitchen cooler. V16 was present and discarded the package. 4. On 4/15/2024 at 10:34AM, the kitchen can opener mounted on a food preparation table was soiled with accumulations of metal shavings and food debris. On 4/17/2024 at 11:13AM, the can opener remained as above. V16 was present, observed the opener, and requested nearby dietary staff to clean and sanitize the can opener. 5. On 4/15/2024 at 10:41AM, the kitchen walk-in cooler evaporator cooling unit was excessively soiled with accumulations of dust. Dust covered the entire front surface of the cooling unit and completely covered both fan guards, with some dust dangling in the air flow produced by the fans. On 4/17/2024 11:16AM, the cooler condenser/evaporator surfaces remained as above. V16 was present (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 14 of 17 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 04/17/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm and reported the facility maintenance department is responsible for cleaning the cooling unit and fan guards. On 4/17/2024 at 11:07AM, V16 reported the food prepared in the facility kitchen is available for all residents to eat. Residents Affected - Many The facility Long-Term Care Facility Application for Medicare and Medicaid (4/15/2024) documents 74 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 15 of 17 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 04/17/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to obtain a culture to ensure that the appropriate antibiotic was being used for one (R8) of two residents reviewed for antibiotic stewardship from a total sample list of 36 residents. Residents Affected - Few Findings include: The facility Antibiotic Stewardship Policy dated 12/18/19 documents that it is the policy of the facility to follow an antibiotic stewardship program and to reduce the inappropriate use of antibiotics. R8's progress notes dated 2/28/24 at 10:03AM, document that R8 has a history of urinary tract infections and that she is sleeping more than usual. R8's progress notes dated 2/28/24 at 12:27PM, document that a urine dip test was performed. On 2/29/24 at 4:40AM, labs were drawn, and fluids were encouraged, but neither a urinalysis nor a culture and sensitivity of the urine was ordered or sent for testing. On 2/29/24 at 12:02PM, Cipro (antibiotic) 500 milligrams was ordered to be administered twice daily for ten days. On 3/16/24 at 2:56PM, V2 Director of Nursing stated that a culture should have been done to ensure that the correct antibiotic was given to treat the infection. R8's progress notes document that on 4/3/24, less than 30 days from the final dose of Cipro given on 3/9/24, R8 had another urinary tract infection that required antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 16 of 17 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 04/17/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer and administer pneumonia vaccine as recommended for residents. These failures affect two of five residents (R21, R48) reviewed for vaccinations in the sample list of 36. Residents Affected - Few Findings include: The facility's Pneumococcal Vaccination policy with a revised date of 8/11/22, Policy: It is the policy of the facility to provide immunizations in accordance with CDC (Centers for Disease Control) recommendations. Procedure: All residents aged 65 years or more and those residents that are determined to be at high risk (those with chronic illness such as lung, heart, or kidney disease, sickle cell anemia, diabetes, recovering from acute illness, those in congregate living environments, with a weakened immune system, etc.{etcetera}) will be offered the Pneumococcal vaccine as recommended by the CDC. 1. All residents will have their immunization status assessed at the time of admission and annually thereafter. Any vaccination that have been received prior to admission will be recorded in the electronic health record. R21's Physician Order Report dated 3/16/24 through 4/16/24 documents R21 was admitted on [DATE] with a diagnosis of Cerebral Palsy and R21 is [AGE] years old. R21's immunization record documents R21 received a PPSV23 (Pneumococcal Polysaccharide Vaccine) on 3/9/20 and according to the CDC vaccine recommendations R21 requires a PCV15 (Pneumococcal conjugate vaccine) or a PCV20 to be up to date on Pneumococcal vaccinations. R48's Physician Order Report dated 3/16/24 through 4/16/24 documents R48 was admitted [DATE] and is [AGE] years old. R48's immunization record documents R48 received a PPSV23 on 12/9/15. R48 requires a PCV15 or PCV20 to be up to date on Pneumococcal vaccinations. On 4/16/24 at 2:05 PM, V9 Registered Nurse/Infection Preventionist stated she has attempted to get R48 to sign a consent for the pneumonia vaccine, but R48 keeps telling her to come back another time. V9 stated that she did not document that anywhere. V9 stated that she didn't think R21 was due for anything, but confirmed after reviewing the guidelines that R21 is due for a PCV15 or PCV20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 17 of 17