Inspection·June 17, 2025

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed on admission to obtain complete physician orders for medication to meet the immediate needs of a resident. This failure affected one (R1) of eight resident reviewed for medications on the sample list of 12. Residents Affected - Few Findings include: R1's current Continuity of Care sheet documents R1 diagnoses Problem list as follows: Paroxysmal Atrial Fibrillation, Unspecified Atrial Flutter, Cardiac Murmur, Unspecified, Essential (primary) Hypertension, Alzheimer's Disease, Unspecified, Vitamin D deficiency, Unspecified, Ascorbic Acid Deficiency, and Vitamin Deficiency, Unspecified. R1's Local Hospital Discharge - Cardioversion Procedure Note, dated 5/12/25, documents R1 had Atrial Flutter (fast heart rate) with rapid ventricular rate of the heart while in the hospital. The rapid heart rate required Electro-Cardioversion (electric shock treatment to the heart) with sedation to convert R1's heart rate to normal sinus rhythm. R1's Local Hospital Discharge Medication List, dated 5/13/25, documents the following incomplete physician orders, when admitted to the facility on [DATE].: *Metoprolol Succinate (Beta-blocker medication that blocks hormones that target the heart) 100 milligram (MG) tablet (tab) SR (sustained release) - 24 hour. Commonly known as: Toprol XL (extended release). The Metoprolol order documents See instructions. There are no instructions documented in the discharge orders that include dosage, route, or time medication is to be administered. *Mirtazapine (Antidepressant medication also used for appetite stimulant.) 30 MG Tabs. Commonly known as: Remeron. The Mirtazapine order documents See instructions. There are no instructions documented in the discharge orders that include dosage, route, or time medication is to be administered. *Fosinopril (Medication treatment for high blood pressure and heart failure) 10 MG Tabs. Commonly known as: Monopril. The Fosinopril order documents See instructions. There are no instructions documented in the discharge orders that include dosage, route, or time medication was to be administered. On 6/12/25 at 10:00 am, V2, Director of Nursing (DON), stated R1's Fosinopril, Metoprolol, and Mirtazapine medication orders were not clarified when R1 was admitted on the 5/13/25 . V2, DON, also stated, This should have been caught immediately when the nurse confirmed the orders on admission. The facility policy Pharmaceutical Procedures, dated 2010, documents the following: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 10 Event ID: 146090 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2025 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)