Inspection·May 1, 2025

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to effectively manage pain, assess for pain, and report pain to the provider for two of three residents (R167, R169) reviewed for pain in the sample list of 28. This failure resulted in R167 experiencing severe pain as evidenced by facial grimacing, missed therapy sessions, and affecting activities of daily living. Residents Affected - Few Findings include: The facility's Pain Management policy, dated 3/3/22, documents the following: Residents will be assessed for pain on admission, quarterly and with any significant change in condition. Residents will be assessed for pain every shift and notify the physician, if needed, regarding pain or pain indicators. Residents will be monitored until pain is resolved/controlled and periodically thereafter. Document pain and the resident's response to medication or treatment. 1.) R167's Hospital Note, dated 4/15/25, documents R167 has right side spasticity, especially to right leg, that is bothersome to R167. Baclofen (muscle relaxant) 5 milligram (mg) daily was started on 4/14/25, and R167 seemed to sleep better through the night. R167's hospital discharge orders, dated 4/23/25, includes Acetaminophen 500 mg by mouth every four hours as needed (PRN) for pain/fever, Baclofen 5 mg by mouth twice daily PRN, Baclofen 15 mg by mouth at bedtime, and Baclofen 5 mg by mouth twice daily. R167's Care Plan, dated 4/24/25, documents R167 was admitted to the facility following hospitalization for stroke, and includes an intervention for pain management as needed. R167's Pain Management Observation, dated 4/23/25, documents R167 was interviewed regarding pain and R167 denied having pain in the last five days. This assessment incorrectly documents R167 did not receive any scheduled or PRN pain medications in the last five days. This assessment documents R167's acceptable level of pain is a 1 on a 1-10 pain scale and rest/relaxation as an alleviating intervention. This assessment does not identify R167's history of pain R167's April 2025 Medication Administration Record documents the following: Acetaminophen PRN dose was given on 4/24/25 at 1:53 AM for generalized pain rated 4, on 4/25/25 at 7:49 AM for hip pain rated 10, on 4/25/25 at 11:32 PM for right leg pain rated 8, on 4/27/25 at 4:29 PM for right leg pain rated 9, and 4/28/25 at 7:29 AM for mild pain, and on 4/28/25 at 12:27 PM for moderate pain. Baclofen PRN dose was given on 4/25/25 at 11:32 PM for right leg spasm pain rated 8, on 4/25/25 at 4:24 PM for leg spasm pain rated 8, and on 4/28/25 at 12:28 PM for moderate leg pain rated 10. There is no follow up pain scale recorded after these medications were administered, and only records if the medication was effective. There were no changes in R167's pain medications until 4/28/25, after R167 was evaluated by V17, Nurse Practitioner (NP). R167's Occupational Therapy Evaluation & Plan of Treatment, dated 4/24/25, documents R167 has right sided hemiparesis and R167 reported right leg pain at rest constantly, rated 7 out of 10. R167 reported right leg pain intermittently with movement rated 8 out of 10. Pain was described as sharp/sudden. R167's Physical Therapy Encounter Note, dated 4/25/25, documents R167 called out in pain due to right leg pain, R167 was found in 90 degree hip and knee flexion. Recommended and instructed nursing staff for R167 to wear right knee immobilizer and lateral positioning wedge for right hip to decrease R167's right hip from rolling outward. R167's Speech Therapy Missed Visit Detail, dated 4/25/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 2 of 10 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 05/01/2025 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 0697 documents therapy session was withheld. R167 was in a lot of pain rated 10 out of 10, and nursing was notified. Level of Harm - Actual harm Residents Affected - Few R167's Nursing Notes document the following: On 4/25/2025 at 6:10 PM, V3, Registered Nurse/RN, noted R167 uses splint/brace for right arm and leg, R167 receives Baclofen and PRN Tylenol for pain. R167 yells out during care. On 4/27/2025 at 11:08 AM, R167 stayed in room for breakfast and had poor appetite. On 4/28/25, R167 did not eat breakfast or lunch. R167 had agitation. R167 reported pain and location, but was unable to rate his pain. R167 was transferred to the hospital following failed attempt of straight catheterization. There is no documentation in R167's medical record that a provider was notified of R167's increased pain that began on 4/25/25, prior to 4/28/25. R167's Encounter Note, dated 4/28/25, recorded by V17, documents verbal orders given to straight catheterize for urinalysis and culture with sensitivity, push oral fluids, and give an additional dose of Baclofen 5 mg with scheduled dose for total of 10 mg due to spastic pain of right lower extremity. On 4/28/25 at 10:58 AM, V19, Certified Nursing Assistant (CNA), upon leaving R167's room, stated R167 is having leg pain, which V19 reported to the nurse. R167 was lying in bed and answered yes to being in pain, but was unable to give any details regarding his pain. At 12:44 PM, R167 was lying in bed with facial grimacing and moaning. R167's lunch tray was at his bedside untouched. V20, R167's Family, stated R169's pain started on 4/25/25, and R167 receives Baclofen and Tylenol. V20 stated Baclofen puts R167 to sleep and R167 has no pain when he is sleeping. V20 stated R167 had been eating prior, so this is new for R167 not to want to eat. On 4/28/25 at 12:38 PM, V19, CNA, and V26, CNA, stated R167 has been in pain since he admitted . V26 stated R167 refused to eat lunch today due to being in pain. V19 and V26 stated R167's appetite varies if he is in pain. On 4/28/25 at 3:29 PM, R167 was in bed and more alert. R167 stated his right leg still hurts like hell, despite receiving pain medications, and his pain has been a 10 off and on. R167 stated his leg pain started yesterday. On 4/28/25 at 3:30 PM, V25, RN, stated R167 was evaluated today by V17, NP, and R167 is being sent to the hospital due to altered mental status and pain. On 4/29/25 at 8:48 AM, V19, CNA, stated R167 mostly complains of pain to his right leg and R167 has been in pain, like he was yesterday, since he admitted . V19 stated R167's medications seem to help him fall asleep, but when they wake him for cares a couple hours later R167 would still be in pain. On 4/29/25 at 11:27 AM, V3, RN, stated R167 had episodes of confusion, but is usually alert and oriented. R167 had a hard time focusing due to right leg spasms, and received Baclofen and Tylenol routinely and as needed, the medications seemed to help and R167 seemed comfortable when sitting. V3 stated R167 would have pain during cares and refused to get out of bed due to pain. On 4/29/25 between 11:45 AM and 11:56 AM, V22, Physical Therapist, stated V22 evaluated R167 on 4/24/25. R167 complained of right leg pain during the evaluation and spasms due to muscle weakness related to his stroke. V22 stated the nurses were aware of R167's pain. V22 stated R167's therapy session on 4/27/25 was cut short due to agitation and being combative. V23, Occupational Therapist, stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 3 of 10 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 05/01/2025 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 0697 on 4/24/25 during R167's therapy evaluation, R167 reported right leg spasms with constant pain and with movement rated a 7 out of 10, and V23 reported this to the nurse. Level of Harm - Actual harm Residents Affected - Few On 4/29/25 at 12:22 PM, V2, Director of Nursing/DON, stated all residents should have an order to assess for pain every shift, and staff should also assess for pain post therapy sessions. V2 stated when PRN pain medications are given, it prompts to enter a pain rating at the time of administration, record follow up if the pain is effective or not effective, but does not prompt for a follow up pain rating. V2 stated if the resident is having excruciating pain that is unrelieved, then the nurses should notify the provider. V2 stated provider notification is recorded in a progress note. V2 stated therapy should be communicating with nursing when residents express pain during therapy, so that it can be discussed during the interdisciplinary team morning meeting. V2 stated V2 did not recall any conversations with therapy regarding R167's pain, other than when the leg immobilizer was initiated. On 4/30/25 at 8:43 AM, V18, Speech Therapist, stated V18 evaluated R167 on 4/24/25. R167 had mild confusion and did not have any complaints of pain. V18 stated V18 attempted to work with R167 on 4/25/25. R167 was lying in bed in pain, R167 would not open his eyes and R167 was grimacing. V18 stated V18 believed it was hip pain and reported R167's pain to the nurse at that time. V18 stated V18 did not provide R167's therapy session due to the amount of pain he was in. On 4/30/25 at 10:07 AM, V17, Nurse Practitioner/NP, stated V17 evaluated R167 on 4/24/25, R167 had spasticity due to a stroke, Baclofen was in use, PRN medications were given, and he was wearing a leg splint. V17 stated, (R167) had pain, it wasn't perfect, but it was controlled, and (R167) appeared comfortable at that time. V17 stated V17 would want to be notified if a resident was experiencing uncontrolled pain, and V17 wasn't notified of R167's pain until Monday morning, 4/28/25. V17 stated a pain rating of 8-10 is quite high, and V17 would have expected the nurses to notify V17. V17 was asked if V17 would have given any new orders if V17 had been notified. V17 stated since it is spasticity driven, V17 might have tried something topical, increased Tylenol to scheduled, and questioned whether his pain was manageable. 2.) R169's admission assessment, dated 4/21/25, documents R169 did not express pain or hurting. This assessment does not include any other questions pertaining to R169's pain history related to left hip fracture. R169's Nursing Note, dated 4/21/2025 at 9:00 PM, documents R169 admitted at 7:15 PM, to receive therapy to build up strength for left hip fracture. R169 was alert and oriented to person, place and time. R169's Care Plan, dated 4/25/25, documents an intervention for pain management as needed. R169's medical record does not document a comprehensive pain assessment was completed until 4/28/25, seven days after R169 admitted to the facility. R169's April 2025 MAR documents on 4/21/25 R169 had left hip rated an 8 on 2nd and 3rd shifts. R169 did not have any pain medication ordered until Acetaminophen was added for 650 mg every six hours was initiated on 4/22/25. R169 has received eight doses of PRN Acetaminophen for left hip pain rated between 4 and 8. This MAR documents the medication was effective, but does not record a follow up pain rating. R169's Acetaminophen order documents the order was entered on 4/22/25 at 8:53 PM. On 4/28/25 at 10:53 AM, R169 was in a wheelchair in R169's room. R169 had left leg above knee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 4 of 10 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 05/01/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few amputation. R169 stated R169 admitted last week after being hospitalized following a left hip fracture from a fall at home. R169 stated R169 receives Tylenol for pain, which hasn't always been effective, but it does help. R169 reported R169's pain has been lessening over time. At 1:41 PM, R169 stated she didn't have any pain medication the first night she admitted to the facility. R169 stated her pain relieved some after she laid down that night. On 4/29/25 at 1:47 PM, V10, Infection Preventionist, stated she assists in completing pain assessments, which are done on admission, quarterly, and with significant changes. V10 stated the floor nurses complete the admission pain assessment, which can be part of the admission assessment. V10 stated if answered yes to pain in the admission assessment pain section, then the assessment prompts further questioning. V10 confirmed the admission assessment pain section is not comprehensive and only asks if the resident is experiencing pain at that moment, and does not assess for history or potential for pain. V10 confirmed R169's admission assessment documents R169 answered no to pain and no further questions were prompted, and R169 did not have a comprehensive pain assessment until 4/28/25. On 4/29/25 at 1:53 PM, V28, NP, stated he was notified on 4/22/25 at 6:30 AM, that R169 was complaining of pain and had no pain medications ordered. V28 stated V28 gave orders for PRN Tylenol and evaluated R169 that day. V28 stated the nurses should have reported R169's pain on 4/21/25, and the need for pain medication orders. On 4/29/25 at 4:07 PM, V21, Licensed Practical Nurse, stated R169 had left hip pain on admission, and the facility did not have any of her medications or prescriptions yet. V21 stated V21 checked with R169 later that evening, and R169 was more comfortable since she was in bed. V21 stated V21 did not report R169's pain to a provider to obtain pain medication orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 5 of 10 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 05/01/2025 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 - 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 given as ordered for four of five residents (R167, R168, R169, R171) reviewed for new admissions in the sample list of 28. Findings include: The facility's Medication Administration policy, dated February 2004, documents the objective of the policy is to provide the residents with medications as deemed necessary by the physician. This policy documents to accurately transcribe physician orders to the Medication Administration Record (MAR) and administer medications as ordered. The facility's Pharmaceutical Procedure, dated 1/5/23, documents convenience drug boxes may be kept by the facility and used to obtain starter or first doses of medications, and normal ordering procedures should be followed to ensure the resident receives a full supply of the ordered medication. This procedure documents to notify the pharmacy of new orders and when medications are removed from the convenience box, so that a replacement can be delivered. 1.) R167's April 2025 MAR documents to give Latanoprost 0.005% one drop right eye daily at bedtime, Rosuvastatin 20 milligrams (mg) daily between 7:00 PM and 10:00 PM, Trazodone 100 mg daily between 7:00 PM and 10:00 PM, and Triamcinolone 0.1% twice daily for 14 days. V16, Registered Nurse (RN), documents these medications were not administered as ordered on the evening of 4/23/25, due to the medications not being available. R167's nursing notes document R167 admitted to the facility on [DATE] at 5:30 PM. There is no documentation the pharmacy or provider were notified of R167's medications being unavailable and missed doses. On 4/30/25 at 10:36 AM, V16, RN, stated medications should be pulled from the backup medication safe, and if unavailable notify the pharmacy, physician, and family. V16 stated this would be documented in a nursing note. V16 thought she notified R167's physician regarding the Latanoprost and received an order to administer to initiate upon the delivery of this medication. V16 stated V16 was unsure if she did any follow up regarding R167's other medications that were not given that evening. 2.) R168's April 2025 MAR documents to give Clarithromycin (antibiotic) 500 mg twice daily for Helicobacter Pylori infection. This medication was documented as not given due to drug being unavailable on the evening of 4/23/25 and both doses on 4/24/25. R168's Nursing Notes document R168 admitted to the facility on [DATE] at 11:30 AM. There is no documentation of communication with pharmacy or the physician regarding Clarithromycin being unavailable and missed doses. On 4/30/25 at 9:56 AM, V24, RN, stated he typically checks the backup medication safe, and pulls medications from there that aren't available. V24 stated if the medication is not in the backup supply, then he notifies the pharmacy and reports missed doses to the physician. V24 stated R168's antibiotic was not a medication that is in the backup supply, and he meant to contact the pharmacy and physician that day. V24 confirmed he did not contact the pharmacy or notify the physician of R167's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 6 of 10 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 05/01/2025 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 missed doses of antibiotic and should have. Level of Harm - Minimal harm or potential for actual harm 3.) R169's April 2025 MAR documents to administer Amitriptyline 25 mg every evening, Aspirin 81 mg twice daily, and Metoprolol Succinate Extended Release 75 mg every evening. These medications were not given as ordered on the evening of 4/21/25 due to condition or due to the medication being unavailable. Residents Affected - Some R169's Nursing Notes documents R169 admitted to the facility on [DATE] at 7:15 PM. There is no documentation as to why the medications weren't given or if the pharmacy or physician were notified. On 4/30/25 at 10:36 AM, V24, RN, stated she is not sure why she documented R169's medications weren't given on the evening of 4/21/25, and V24 thought she obtained R169's medications from the facility's backup supply safe. On 4/30/25 at 11:53 AM, V2, Director of Nursing (DON), provided a report of medications pulled from the facility's backup medication safe. V2 confirmed there was no documentation that 169's medications were obtained from the backup safe. 4.) R171's Hospital Discharge Orders, dated 4/26/25, documents to administer Levofloxacin (antibiotic) 750 mg every 48 hours for three doses for Urinary Tract Infection, to start on 4/27/25. This order was incorrectly transcribed to R171's MAR. R171's April 2025 MAR documents R171 to give Levofloxacin on 4/27/25 and 4/30/25, which is 72 hours apart. This MAR documents to give Atorvastatin 40 mg by mouth every evening. This medication was not administered on the evening of 4/21/25 due to the medication being unavailable. R171's Nursing Notes do not document communication with the pharmacy or provider regarding Atorvastatin being unavailable to administer. On 4/30/25 at 10:36 AM, V24, RN, stated V24 was unsure if V24 did any follow up regarding R171's Atorvastatin being unavailable or reported the missed dose. On 4/30/25 at 10:45 AM, V2, DON, stated the nurses should check the backup medication safe for medications and if the medication is not included, then the nurse needs to notify the backup pharmacy to obtain the medication. V2 stated the backup pharmacy can take awhile to deliver, so the nurse should notify the physician of a possible delay in the delivery of the medication. V2 stated the nurse should also notify the resident and representative. V2 stated this communication should be documented in a nursing note. V2 confirmed R171's Levofloxacin order was incorrectly transcribed to administer 72 hours apart, rather than 48 hours as ordered. At 11:53 AM, V2 provided the reports for medications pulled from the backup medication safe. V2 confirmed the medications listed as being unavailable for R167, R168, and R171 were not obtained from the facility's backup medication safe on the dates listed as being omitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 7 of 10 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 05/01/2025 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 implement antibiotic stewardship by failing to ensure symptoms meet urinary tract infection (UTI) criteria and obtain/review urine cultures for four of six residents (R18, R19, R48 R52) reviewed for antibiotic stewardship in the sample list of 28. Residents Affected - Some Findings include: The facility's Antibiotic Stewardship policy, dated 12/18/19, documents the purpose of the policy is to reduce the inappropriate use of antibiotics, improve resident outcomes, and reduce adverse events. This policy documents the facility uses McGreer Criteria as part of its Infection Control Program and the facility will track antibiotic use daily. The Revised McGreer Criteria for Infection Surveillance Checklist, dated 11/5/24, documents for UTIs without indwelling urinary catheters surveillance definition: Must fulfill both 1 AND 2. 1. At least one of the following sign or symptom Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and one or more of the following: Acute costovertebral angle pain or tenderness Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency If no fever or leukocytosis, then at least two of the following: Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 8 of 10 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 05/01/2025 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 2. At least one of the following microbiologic criteria: Level of Harm - Minimal harm or potential for actual harm at least 100,000 cfu/mL (colony forming units per milliliter) of no more than 2 species of organisms in a voided urine sample at least 10,000 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter Residents Affected - Some The facility's January 2025-March 2025 Resident Infection Control logs document the following: R52 had burning with urination, was treated with Ciprofloxacin (Cipro) 500 milligrams (mg) twice daily 1/7/25-1/11/25, and no culture was completed. R19 was treated for UTI with Cipro 500 mg twice daily 2/14/25-2/20/25, no recorded symptoms, and culture showed mixed flora R18 was treated for UTI with Nitrofurantoin 100 mg twice daily from 2/28/25-3/1/25, no recorded symptoms, and no culture was obtained. R48 was treated for UTI with Keflex 500 mg twice daily from 3/7/25-3/11/25, culture was done at the hospital, and not applicable for the organism. 1.) R52's January 2025 Cipro Medication Administration Record (MAR) documents 500 mg administered twice daily as ordered from 1/7/25-1/11/25. R52's Nursing Note, dated 01/06/2025 at 5:54 PM, documents R52 complained of hurting and burning with urination, urine was dipped with positive results for leukocytes, nitrites, protein, blood, and ketones. V28, Nurse Practitioner/NP, notified and awaiting new orders. There is no documentation in R52's medical record the facility consulted with the provider on whether a urine culture was needed. There is no documentation in R52's medical record that a McGreer form was completed for R52's UTI treatment. 2.) R19's February 2025 MAR documents R19 received Nitrofurantoin 100 mg twice daily from 1/31/25-2/5/25 for UTI and Cipro 500 mg twice daily from 2/14/25-2/20/25 for acute cystitis. R19's Nursing Note, dated 02/09/2025 at 2:09 PM, documents R19 had green colored vaginal discharge, provider notified and ordered urinalysis. R19's Nursing Note, dated 2/13/2025 at 10:40PM, documents new order received for Cipro, R19 voiced no complaints of pain, burning, or itching upon urination. There is no documentation in R19's medical record that a McGreer form was completed for R19's UTI treatment. 3.) R18's March 2025 Nitrofurantoin MAR documents 100 mg was given twice daily as ordered from 3/1/25-3/5/25. R18's Nursing Notes document R18 started Azithromycin on 2/22/25 for bronchitis, R18 was sent to the emergency room on 2/28/25, returned on 3/1/25, and started antibiotics for UTI. R18's urine culture, dated 2/28/25, documents greater than 100,000 cfu/ml of Escherichia Coli and resistance to Nitrofurantoin. This culture has a print date of 4/30/25, and there is no documentation this culture was reviewed during R18's UTI treatment or follow up with a physician that the organism was not sensitive to the antibiotic prescribed. 4.) R48's March 2025 Keflex MAR documents 500 mg was given twice daily from 3/7/25-3/11/25. R48's medical record did not contain a urine culture for this UTI treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 9 of 10 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 05/01/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R48's Urine Culture, dated 3/3/25, documents greater than 100,000 cfu/ml of Escherichia Coli. This culture has a print date of 4/30/25. On 4/30/25 at 2:02 PM, V10, Infection Preventionist, stated, We try not to test urine for just confusion and try to push fluids instead. If no improvement, then we dip the urine here at the facility, report the results to the provider, and send a sample for a culture and sensitivity (C&S). C&S is used to determine appropriate prescribing of antibiotics. The cultures completed at the hospital are reviewed. V10 confirmed the facility's infection control logs do not document symptoms and/or urine cultures for R18, R19, R48, and R52. V10 stated R19 had burning and frequency that was reported to the physician who ordered the antibiotic. V10 was asked to provide documentation of symptoms and cultures for the UTI treatment for these residents. On 4/30/25 at 3:25 PM, V2, Director of Nursing, stated, (R52's) family had requested her urine be tested, the nurse dipped her urine, and notified (V28) who gave orders to start an antibiotic but did not order a urine culture. V10 provided R18's urine culture, and confirmed the bacterial organism was resistant to the ordered antibiotic, and there was no follow up regarding this. V10 confirmed the culture results were obtained today. At 3:51 PM, V10 provided R48's urine culture and confirmed the results were obtained today. V10 stated at least two symptoms are needed, per McGreer criteria to be met. V10 stated McGreer form should be completed for UTIs and this would be uploaded in the observation section of the resident's electronic medical record. V10 confirmed there was no McGreer form completed for R19's UTI, and the only documented symptom was green vaginal discharge. V10 stated R19 had been on antibiotic prior for UTI, R19 was off antibiotics for seven days. R19's urine culture showed mixed flora, and no repeat culture was obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146090 If continuation sheet Page 10 of 10