Hawthorne Inn Of Danville

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

perform hand hygiene or glove changes after cleansing Resident R4's wound, prior to applying the clean dressing.

V10 stated V10 thought this was only needed after removing the soiled dressing. On 8/13/25 at 11:00 AM, V8, RN, stated V8 has been filling in as the wound nurse. V8 confirmed V30 ordered skin protectant treatment for Resident R4's heels on 8/5/25, and confirmed this order was not entered into Resident R4's EMR. V8 confirmed bordered foam dressings changed every five days is Resident R4's current/active treatment order. V8 stated the treatment is for protection of Resident R4's heels. V8 stated V30's orders and notes are given to V8 or V2, Director of Nursing, to enter into the resident's EMR. V8 stated the nurses should perform hand hygiene and glove changes after each step of the wound treatment, including after cleaning the wound.

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Printed: 04/13/2026 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

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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure medical records are complete and accurate for one of four residents (Resident R1) reviewed for injuries in the sample list of eight. Findings Include:Resident R1's Nursing Notes document Resident R1 admitted to the facility from the hospital on 7/10/25. Resident R1's Nursing Notes, dated 7/10/25, do not document an assessment of Resident R1's skin or if Resident R1 had any skin issues or bruising. Resident R1's Nursing Note, dated 7/13/25 at 3:39 PM, documents Resident R1's incisions to left thigh, right groin, and chest are closed. There is no documentation in Resident R1's nursing notes between 7/10/25 and 7/16/25 that Resident R1 had any bruising. Resident R1's admission Observation, dated 7/10/25, documents there were no alterations in Resident R1's skin. Resident R1's Skin Assessment, dated 7/16/25, documents, Incisions & bruising. No new areas of concern. This assessment does not document the location of Resident R1's bruising. On 8/13/25 at 8:31 AM, V10, Registered Nurse, stated Resident R1 admitted to the facility five weeks post Coronary Artery Bypass Grafting (CABG). V10 stated Resident R1 had closed incisions to the groin, leg, and chest that were left open to air and no treatment needed. V10 stated Resident R1 also had bruising to her hip or rib area. V10 stated nurses document weekly skin assessments and admission skin assessments under the observations section of the resident's electronic medical record, and this may also be noted in a nursing note. At 9:26 AM, V10 stated the bruising V10 documented in Resident R1's skin assessment note 7/16/25 was the bruising V10 previously mentioned. V10 stated V10 did not consider the bruising to be a new issue since it was previously reported on Resident R1's admission. V10 stated V10 had received report from the hospital the day Resident R1 admitted and was told Resident R1 had hip bruising. On 8/13/25 at 9:11 AM, V2, Director of Nursing, stated Resident R1 admitted with bruising following CABG. V2 confirmed Resident R1's admission assessments, skin assessments, and notes do not document Resident R1 admitted with incisions or bruising. V2 stated V2 has requested Resident R1's provider progress notes and is waiting on V29, Nurse Practitioner, to send Resident R1's notes to the facility and obtain documentation that Resident R1 had hip bruising on admission. Resident R1's Progress Note, dated 7/11/25, recorded by V29 documents Resident R1 was hospitalized on [DATE REDACTED] and underwent left heart catheterization; Resident R1 underwent two vessel CABG on 6/5/25 and developed a right femoral arterial sheath hematoma. This note documents Resident R1 had a midsternal incision that was dry and open to air, with no drainage or inflammation noted. This note documents Resident R1's left medial thigh incision from vein graft site was open to air, healed, and dry. This note was included in Resident R1's provider progress notes, provided by V2, with a facsimile cover sheet documents Resident R1's notes were sent to the facility from V29 on 8/13/25 at 8:56 AM. The facility's Job Description Medical Records, dated May 2013, documents responsibilities includes tracking and monitoring physician visits/notes, uploading documentation into the resident's electronic medical record, conducting audits of resident medical records and reporting discrepancies to the Director of Nursing.

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