Hawthorne Inn of Danville

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records are complete and accurate for one of four residents (R1) reviewed for injuries in the sample list of eight. Findings Include:R1's Nursing Notes document R1 admitted to the facility from the hospital on 7/10/25. R1's Nursing Notes, dated 7/10/25, do not document an assessment of R1's skin or if R1 had any skin issues or bruising. R1's Nursing Note, dated 7/13/25 at 3:39 PM, documents R1's incisions to left thigh, right groin, and chest are closed. There is no documentation in R1's nursing notes between 7/10/25 and 7/16/25 that R1 had any bruising. R1's admission Observation, dated 7/10/25, documents there were no alterations in R1's skin. R1's Skin Assessment, dated 7/16/25, documents, Incisions & bruising. No new areas of concern. This assessment does not document the location of R1's bruising. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview the facility pharmacy repeatedly failed to provide medications in a timely manner. This failure affects one (R1) of eight residents reviewed for medications on the sample list of 12.

Inspectors wroteBased on record review and interview, the facility failed to prevent significant medication errors by failing to clarify incomplete hospital physician ordered medications on admission in a timely manner, and failed to obtain medication from the pharmacy in a timely manner. These failures resulted in multiple missed doses of heart and blood pressure medication administration after electro-cardioversion, and missed doses of antidepressant/appetite stimulant medications. This failure affects one (R1) of eight residents reviewed for medications on the sample list of 12.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one (R1) of twelve resident reviewed medical record accuracy on the sample list of 12.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall by failing to utilize a blind spot mirror before opening a door for one (R58) of three residents reviewed for falls on the sample list of 28. Findings Include: R58's electronic health record documents R58 was admitted to the facility on [DATE] for skilled nursing and rehab. On 4/28/2025 at 10:05 AM, R58 was observed walking back and forth down the halls and around the memory care unit with R58's four wheeled walker. R58's fall investigation report, dated 4/11/2025, documents R58 had a fall at 4:59 PM. This report documents R58 was ambulating in the hallway on the memory lane unit close to the front door, when V12 (Dietary Aide) opened the door, bumping R58. R58 lost her balance and fell. This report also documents V13 (Certified Nursing Assistant) witnessed the fall. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label TCS (time/temperature control for safety) food, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food storage equipment. These failures have the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to timely complete Minimum Data Set (MDS) assessments for four (R4, R44, R49, R58) of 18 residents reviewed for MDS assessments in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to timely transmit a Minimum Data Set (MDS) assessment for one (R35) of 18 residents reviewed for MDS assessments in the sample list of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received the recommended/ordered amount of Enteral feeding for two of two residents (R53, R11) reviewed for Enteral feedings in the sample list of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain Physician's Orders for oxygen administration and failed to care plan for the use of oxygen for one of two residents (R32) reviewed for oxygen use in the sample list of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately and routinely assess side rail use per the facility's policy, obtain consent for side rail use, document alternative interventions attempted prior to use, and care plan for side rails for two (R9, R59) of two residents reviewed for siderails in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to complete quarterly psychotropic mediation assessments, failed to identify/document/care plan specific targeted behaviors and nonpharmacological interventions, failed to include a duration for a PRN (as needed) psychotropic medication order, failed to failed to obtain/document consent for psychotropic medication use, and failed to rule out underlying causes of behaviors prior to initiating psychotropic medications for three (R58, R78, R36) of five residents reviewed for unnecessary medications in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to obtain a culture to ensure that the appropriate antibiotic was being used for one (R8) of two residents reviewed for antibiotic stewardship from a total sample list of 36 residents.

Inspectors wroteBased on interview and record review the facility failed to offer and administer pneumonia vaccine as recommended for residents. These failures affect two of five residents (R21, R48) reviewed for vaccinations in the sample list of 36.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure that a resident was afforded privacy during G-Tube (Gastrostomy Tube) medication administration. This failure affected one (R50) of 26 residents reviewed for privacy of the sample list of 26.

Inspectors wroteBased on record review, observation and interview the facility failed to provide safe Gastrostomy tube (tube surgically inserted into the stomach through the abdomen) administration of medication according to standard of practice and physician order. This failure affected one of one resident (R50) reviewed for Gastrostomy tube medication administration on sample of 26.