Inspection·August 13, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent cross contamination during wound care and implement pressure ulcer treatments for one of four residents (R4) reviewed for wounds in the sample list of eight. Findings Include: The facility's Wound Care policy, dated 10/16/24, documents wounds are subject to infection, and to wash your hands and wear gloves as part of wound care. This policy documents follow physician's orders for wound care and enter physician's orders into the resident's electronic medical record (EMR). R4's Hospital Discharge Transfer Orders, dated 7/31/25, document R4 has an unstageable pressure ulcer of the coccyx and a deep tissue injury to the right heel. R4's active care plan documents R4 admitted to the facility on [DATE], and includes an intervention for wound treatments and dressing changes per physician's order. R4's Initial Wound Evaluation & Management Summary, dated 8/5/25, recorded by V30, Wound Physician, documents R4's stage two pressure ulcer of right heel measured 2 centimeters (cm) long by 0.8 cm wide, and depth is unmeasurable due to presence of tissue overgrowth. The treatment ordered for this wound is skin protectant daily and as needed. This summary documents R4's stage four sacral pressure ulcer measured 6.5 cm by 5.5 cm, and depth is unmeasurable due to the presence of nonviable tissue and necrosis (dead tissue). This wound was initially unstageable and debrided by V30 to remove the dead tissue, which revealed the wound to be a stage four pressure ulcer, and not a deterioration of the wound. R4's physician's order history, dated 7/13/25-8/13/25, includes an order, dated 8/6/25, for stage four sacral pressure ulcer treatment, cleanse with wound cleanser/normal saline, apply Dakin's (bleach solution) soaked gauze to wound bed, cover with abdominal pad, and secure with tape twice daily and as needed. This order history includes an order, dated 8/1/25-8/13/25, to apply bordered antimicrobial foam dressing to bilateral heels, change every five days. This order history does not document V30's order for skin protectant to R4's heels prior to 8/13/25. On 8/11/25 at 11:21 AM, R4 stated R4 admitted to the facility with a sore on R4's bottom, and V30 removed dead tissue from the wound. R4 stated R4 also had a sore on his heel that he admitted with, but believes it is healed now. On 8/11/25 at 11:26 AM, V17, Certified Nursing Assistant, stated R4 used to have a sore on his heel, but it is now healed. V17 removed R4's socks and there were no dressings covering R4's heels. R4's skin to the left heel was intact, and the right heel had a red,, intact wound. On 8/13/25 at 10:23 AM V10 Registered Nurse (RN), with V17 present, provided R4's sacral wound treatment. V10 removed R4's soiled sacral dressing, washed hands, and changed gloves. R4 was lying in bed and had a golf ball sized open, deep wound to the left buttock/sacral area. The wound bed was pink with a minimal amount of yellow tissue. V10 cleansed the wound with wound cleanser and gauze, and did not perform hand hygiene or change gloves, prior to applying the Dakin's soaked gauze and bordered foam dressing. V10 removed R4's shoes and socks and there were no dressings on R4's heels. There was a small red, intact wound to the right heel. V10 stated the right heel wound was present on admission and was never open. On 8/13/25 at 10:35 AM, V10 confirmed V10 did not Residents Affected - Few (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 3 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 08/13/2025 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)