Hawthorne Inn of Danville

In the surveyor’s words

From the most serious findings on record at Hawthorne Inn of Danville, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Apr 7, 2021

  Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to provide treatment and services to prevent worsening pressure ulcers for residents. The facility failed to assess, identify, treat and monitor pressure sores. The facility failed to train staff in the provision of pressure ulcer care and prevention. These failures affect 2 of 4 residents (R1, R2) reviewed for pressure ulcers in the sample of four. These failures resulted in R1's pressure wound to R1's left heel progressing from a stage I pressure injury to a wound with visible ligaments and tendons in the wound bed. […]

• Actual harm, isolatedF697May 1, 2025

  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. 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. […]

• Actual harm, isolatedF600Jan 11, 2023

  Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident for one of three residents (R2) reviewed for physical abuse in a sample list of three residents. This failure resulted in R1 intentionally striking R2 on the head with an object and R2 subsequently suffering a laceration requiring six sutures in the hospital emergency department. Findings include: R2's Minimum Data Set, dated dated dated [DATE] documents R2's diagnoses including: Alzheimer's Disease, Cerebral Vascular Accident, Hypertension, Hyperlipidemia, Hip Fracture, and Anxiety. R2's minimum data set documents R2 as severely cognitively impaired and requiring extensive assistance with mobility and no history of behaviors. […]

• Actual harm, isolatedF686Jul 6, 2022

  Based on observation, interview, and record review the facility failed to remove a splint during skin assessments to assess for and prevent pressure ulcers for one resident (R2). This failure resulted in R2 developing an unstageable necrotic wound to the right heel. The facility also failed to implement pressure relieving interventions and notify the physician timely of a new pressure ulcer for one (R2) of three residents reviewed for wounds in the sample list of 14. Findings include: R2's Face Sheet dated 7/6/22 documents R2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF801Apr 17, 2024

  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. 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. […]