Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Danville Post-acute Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for care was slapped on the face by a family representative during feeding, resulting in redness and swelling. The incident was witnessed by a housekeeper and confirmed by an LPN, with documentation of the injury in the resident's records. Facility policy required protection from abuse, but this was not ensured in this case.
A facility failed to provide a complete set of medical records to a resident's designated legal representative, violating the resident's rights. Despite a written request, the facility did not include essential documents such as nursing notes and the MAR. The Medical Records Supervisor confirmed the omission, which contravenes HIPAA requirements for access to medical information.
Two residents in a facility were inaccurately assessed in their quarterly MDS assessments. One resident was incorrectly coded as having pneumonia, despite no evidence of the condition, while another resident's verbal behavioral symptoms were not documented, despite daily occurrences. These inaccuracies were due to oversight and failure to review relevant documentation, as confirmed by staff interviews.
A resident in the facility had long toenails and expressed a desire for them to be trimmed, but the necessary care was not provided. The resident required assistance with personal hygiene, as indicated in her MDS assessment. Interviews with staff revealed that CNAs and licensed nurses were responsible for toenail care, but there was no documentation of attempts or interventions to address this need, despite the facility's policy requiring daily and as-needed services.
The facility failed to properly manage lidocaine patches and controlled medications for several residents. Nursing staff did not remove lidocaine patches after 12 hours as required, potentially leading to excessive dosing. Additionally, discrepancies were found between the Controlled Drug Records (CDR) and Medication Administration Records (MAR) for controlled medications, raising concerns about drug accountability and resident pain management. The facility's policy requires accurate documentation, which was not followed, indicating potential risks of drug diversion.
A facility failed to monitor and document side effects of haloperidol in a resident with dementia and psychotic disturbances. The resident exhibited involuntary jaw movements, a potential side effect, which were not recorded in the MAR or reported to medical staff. Interviews revealed staff noticed the movements but did not recognize them as symptoms of tardive dyskinesia. The care plan required monitoring and reporting of side effects, which was not adequately followed.
A survey found a 6.67% medication error rate in an LTC facility. One error involved an LVN preparing the wrong dose of Eliquis for a resident, intercepted by a surveyor. Another error involved administering a potassium chloride capsule instead of a tablet to a resident, without a physician's order. The facility's policy requires medications to be administered as per physician's orders.
The facility failed to properly label and store medications, as an unlabeled box of Artificial Tears containing a Refresh Tears bottle was found in a medication cart. An LVN confirmed the issue, and the DON stated that opened eye drops should be labeled with the resident's name and date opened.
The facility failed to store perishable food items according to professional standards, with expired fruit juices and apples found in the kitchen. Additionally, the floor beneath Refrigerator 2 in the dry storage room was unclean, with a grease stain and particles present. These issues could lead to foodborne illnesses for the 38 residents consuming food from the kitchen.
A facility failed to maintain accurate MARs for controlled substances, with discrepancies found in the records of three residents. The electronic MARs were altered, and staff interviews revealed confusion about documentation procedures. The DON emphasized the need for real-time documentation, but LVN 3 admitted to making changes without consulting others. The facility's policies require prompt and accurate documentation, which was not followed, and electronic audit logs were unavailable.
A facility failed to maintain privacy and confidentiality for a resident by leaving diet and aspiration precautions uncovered and visible in a shared room. The signage, which included detailed health information, was exposed to unauthorized individuals, violating HIPAA regulations. Staff acknowledged the signage's presence but did not take action to cover it, despite the facility's policy on confidentiality.
A resident with a history of hypertension and atrial fibrillation experienced untreated edema in both feet for at least 24 hours, leading to discomfort and pain. The facility staff failed to assess, document, and communicate the condition to a physician, despite the facility's policy requiring such actions. The Director of Nursing expected staff to notice and act on health changes, but this was not done in this case.
Two residents with indwelling urinary catheters were found with their catheter bags and tubes touching the floor, contrary to the facility's infection control procedures. Staff acknowledged the risk of infection from this practice, and the facility's policy emphasized keeping catheters off the floor. Despite these guidelines, the deficiency was observed during a survey.
A resident with a PICC line did not receive IV antibiotics on time, as required by physician orders, due to inconsistent administration by nursing staff. Additionally, during a PICC line dressing change, the facility failed to measure the resident's arm circumference, a critical step for monitoring potential complications. These actions were contrary to the facility's policies, potentially affecting the resident's treatment effectiveness.
A facility failed to follow infection control practices when an LVN handled a medication capsule without gloves and another LVN did not change gloves or wash hands after touching a contaminated catheter bag before adjusting a resident's nasal cannula. The DON confirmed the need for gloves during medication handling and proper glove removal and handwashing after contamination.
A resident with a high fall risk and multiple medical conditions fell and fractured her hip after being left unattended on the facility's patio by a PTA. The resident was in severe pain and required hospitalization. The facility's failure to ensure proper supervision and communication led to this incident.
Failure to Protect Resident from Physical Abuse by Family Representative
Penalty
Summary
A resident with severe cognitive impairment, dependent on staff for all activities of daily living due to dementia and dysphagia following a stroke, was admitted to the facility. On the morning of 5/21/25, the resident's family representative attempted to feed the resident and, when the resident did not open their mouth, slapped the resident on the left side of the face. This incident was witnessed by a housekeeper, who observed the family representative striking the resident and then leaving the room. Following the incident, the charge nurse noted redness and slight swelling on the resident's left cheekbone. The resident was unable to provide information about the event due to their cognitive status. Facility records confirmed the physical findings, and staff interviews indicated that the family representative had a history of not listening to staff instructions. The facility's policy required protection of residents from all forms of abuse, but this was not upheld in this instance.
Failure to Provide Complete Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide a complete set of medical records to the designated legal representative of a resident, thereby not honoring the resident's rights. The deficiency was identified during a review of the resident's face sheet and subsequent interviews. The resident was admitted to the facility and later discharged to an acute care hospital. A written request for all medical records was submitted by the resident's designated legal representative, but the facility did not provide the complete set of records, including nursing progress notes, social services notes, assessments, and the Medication Administration Record (MAR). During interviews with the Medical Records Supervisor, it was confirmed that the full set of medical records, which are crucial clinical documents, were not provided as requested. The facility's policy and procedures under HIPAA require that individuals have the right to inspect and obtain copies of their medical information. However, the facility did not comply with these requirements, as the requested records were not fully provided, leading to a violation of the resident's rights.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents in their quarterly Minimum Data Set (MDS) assessments, leading to an outdated and inaccurate reflection of their medical and clinical status. Resident 18's MDS assessment was incorrectly coded as having an active diagnosis of pneumonia, despite no evidence of such a condition during the look-back period. Interviews with the resident, a CNA, an LVN, and the MDS Coordinator revealed that there were no signs or symptoms of pneumonia, and the diagnosis was mistakenly based on a progress note indicating wheezing and other respiratory issues, but not pneumonia. The Director of Nursing acknowledged that inaccurate MDS assessments could lead to unsafe care. Resident 7's MDS assessment was inaccurately coded as having no verbal behavioral symptoms, despite documentation in the Medication Administration Record (MAR) indicating daily episodes of verbal hostility during the look-back period. The Case Manager admitted to not reviewing the licensed nurses' notes when completing the behavior assessment, resulting in the incorrect coding. The Director of Nursing confirmed that the behavior assessment should have been accurately coded, as incorrect documentation could affect the resident's overall care. The facility's policy and procedure on the accuracy of assessments, as well as the CMS's RAI Manual, emphasize the importance of accurate documentation to reflect the resident's status and to develop appropriate care plans. The failure to adhere to these guidelines resulted in the deficiencies noted in the assessments of Residents 18 and 7.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care and hygiene for a resident, identified as Resident 11, who was admitted in December 2022. During an observation and interview, it was noted that Resident 11 had toenails approximately an inch long on both feet and expressed a desire for them to be trimmed. The resident's Minimum Data Set (MDS) assessment indicated that she required setup or clean-up assistance to maintain personal hygiene. Despite this, the necessary care was not provided, leading to the deficiency. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON), revealed that CNAs and licensed nurses were responsible for trimming the resident's toenails. The ADON acknowledged the importance of toenail trimming to prevent infections and maintain hygiene. However, there was no documentation of attempts or interventions to address the resident's toenail care needs, particularly from August to October 2024, despite the facility's policy requiring daily and as-needed services for residents unable to perform activities of daily living.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure the proper use of lidocaine patches for two residents, Residents 27 and 194. The nursing staff did not remove the lidocaine patches after 12 hours as ordered by the prescriber and per manufacturer recommendations. This oversight was observed during a medication pass, where the patches were found to have been left on overnight and removed by the morning nurse. The Director of Nursing (DON) and Consultant 1 confirmed that the patches should have been removed the previous night, and the Consultant Pharmacist emphasized the importance of adhering to the 12-hour removal schedule to prevent excessive dosing and potential side effects. Additionally, the facility did not maintain accurate accountability of controlled medications for four residents, Residents 2, 10, 240, and 241. The Controlled Drug Records (CDR) did not reconcile with the Medication Administration Records (MAR), leading to discrepancies in the documentation of medication administration. For instance, doses were signed out on the CDR but not documented on the MAR, and vice versa. The DON acknowledged these discrepancies and expressed concern about the potential impact on residents' pain management. The facility's policy on controlled substances requires accurate accountability of all controlled drugs, with immediate documentation on both the CDR and MAR by the administering nurse. However, the observed discrepancies indicate a failure to adhere to this policy, raising concerns about the potential for drug diversion and the accuracy of residents' medical records. The Consultant Pharmacist highlighted the importance of matching the MAR, CDR, and physical tablet count to prevent such issues.
Failure to Monitor and Document Side Effects of Haloperidol
Penalty
Summary
The facility failed to accurately monitor, document, and intervene for potential side effects of haloperidol in a resident with unspecified dementia and psychotic disturbances. The resident was observed to have abnormal, consistent, involuntary lateral movements of the jaw while talking, which were not documented as side effects in the Medication Administration Record (MAR) from late September to early October. Despite these observations, the resident's Abnormal Involuntary Movement Scale (AIMS) assessment indicated minimal/normal movements around facial muscles without specifying the exact area, and the movements were not reported to the medical doctor or pharmacy. Interviews with staff revealed that both a Certified Nursing Assistant and a Licensed Vocational Nurse had noticed the resident's recurrent jaw movements but did not recognize them as potential symptoms of tardive dyskinesia, a known side effect of haloperidol. The Assistant Director of Nursing acknowledged the importance of involving the care team to investigate the medications more closely. The resident's care plan required monitoring and documentation for side effects, consulting with pharmacy and physician for dosage reduction, and reporting adverse reactions, but these actions were not adequately followed, leading to the deficiency.
Medication Errors in LTC Facility
Penalty
Summary
The facility experienced a medication error rate of 6.67% during a survey, with two errors occurring out of 30 opportunities. The first error involved a licensed vocational nurse (LVN) who mistakenly prepared a 2.5 mg Eliquis tablet from another resident's medication pack for Resident 27, instead of the prescribed 5 mg dose. This error was intercepted by the surveyor before administration. Resident 27 had a physician's order for Eliquis 5 mg twice daily for blood clot prevention, while the medication prepared was intended for Resident 194, who was prescribed Eliquis 2.5 mg for atrial fibrillation. The Director of Nursing acknowledged the error during an interview. The second error involved another LVN who administered a potassium chloride extended-release capsule to Resident 33, instead of the prescribed tablet form. The LVN confirmed the administration of the capsule, which was not therapeutically equivalent to the tablet as per the Orange Book. Resident 33 had a physician's order for potassium chloride extended-release 10 mEq oral tablet twice daily. The facility's policy required medications to be administered according to the physician's written orders, and any changes in medication form should have been communicated with the pharmacy or physician. The Director of Nursing and Consultant Pharmacist confirmed the need for a new order before switching medication forms.
Improper Labeling and Storage of Eye Drops
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications according to its policy and procedures, as well as manufacturer's specifications. During an observation and interview, an unlabeled box of Artificial Tears eye drops was found in a medication cart, containing an unlabeled eye dropper bottle of Refresh Tears. The Licensed Vocational Nurse (LVN) present confirmed the observation and admitted to not knowing the owner of the eye drops or why they were in the incorrect box. The Director of Nursing (DON) later confirmed that opened eye drops should be labeled with the resident's name and the date they were opened.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety by improperly storing perishable food items and neglecting cleanliness in the kitchen area. During an inspection, it was observed that several containers of fruit juices in Refrigerator 1 were labeled with use-by dates that had already passed, indicating that these items were expired and should have been discarded. Additionally, a bin containing apples in the dry goods storage area was found to have a use-by date that had also expired. The Dietary Manager confirmed that these items were beyond their use-by dates, which is a violation of the facility's policy on labeling and dating foods. Furthermore, the facility did not maintain cleanliness in the kitchen's dry storage room, as evidenced by the condition of the floor beneath Refrigerator 2. The floor was observed to have a dark, shiny stain and granular particles, which were later identified as grease by the Environmental Services staff. This lack of cleanliness is contrary to the U.S. Food and Drug Administration Federal Food Code, which mandates that food storage areas be kept clean to prevent contamination. These deficiencies had the potential to cause foodborne illnesses among the 38 residents who consumed food prepared in the facility's kitchen.
Inaccurate MARs for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate medication administration records (MARs) for controlled substances, which are medications with a high potential for abuse and addiction. During a survey, it was discovered that the electronic MARs for three residents were altered. Specifically, the MARs for Residents 10, 240, and 241 showed discrepancies between records printed on different dates. For instance, Resident 241's MAR printed on one day showed different entries compared to the MAR printed the previous day. The Director of Nursing (DON) and a consultant acknowledged these discrepancies, and it was noted that the electronic medical record system does not allow back-filling of administration entries, which should be documented at the time of administration. Interviews with facility staff revealed a lack of clarity and adherence to proper documentation procedures. The Assistant Director of Nursing (ADON) mentioned that MAR entries could be edited after the date had passed, although she was unsure of the exact cutoff. Consultant 1 confirmed that MAR entries could be edited after the fact but did not comment on whether this was acceptable. The DON emphasized the importance of documenting medication administration in real-time and expressed concern about the practice of back-filling MARs, although she did not specify the exact dangers involved. Further investigation showed that Licensed Vocational Nurse (LVN) 3 made the changes to the MARs without direction from facility leadership. LVN 3 admitted to altering the records without consulting anyone and acknowledged that MAR entries should be completed timely to inform subsequent shifts. The facility's policies and procedures require prompt and accurate documentation of medication administration, and the failure to adhere to these standards was evident in the discrepancies found in the MARs. Additionally, the facility was unable to provide electronic audit logs for the MARs, further complicating the issue of accountability and accuracy in record-keeping.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain privacy and confidentiality for a resident when diet and aspiration precautions were left uncovered and posted on the wall by the resident's head of the bed. This resident shared a room with two other residents, and the care instructions were visible to staff not engaged in her care and visitors for other residents sharing the room. The signage included detailed health information such as aspiration precautions and dietary recommendations, which were not covered, thus violating privacy regulations. During observations and interviews, it was noted that the signage had been visible for several months, with staff members acknowledging its presence but not taking action to cover it. The facility's policy on confidentiality, which aligns with HIPAA regulations, was not followed in this instance, as the resident's health information was exposed to unauthorized individuals. The resident involved had severe cognitive impairment, as indicated by a BIMS score of zero, and was unable to advocate for her privacy needs.
Failure to Assess and Treat Edema in Resident
Penalty
Summary
The facility failed to assess, evaluate, and treat edema in both feet of a resident for at least 24 hours, resulting in discomfort, pain, and limited range of motion. The resident, who was admitted in January 2023, had a history of hypertension and paroxysmal atrial fibrillation, and her cognition was moderately impaired. During an observation, the resident reported that her feet had been swollen for days without being checked by the facility staff. A Licensed Vocational Nurse (LVN) confirmed the presence of pitting edema in the resident's feet, which had not been documented or communicated to a physician. The Director of Nursing (DON) stated that direct care staff were expected to notice and act upon any changes in a resident's health condition daily, including documenting and notifying the medical doctor of such changes. However, a review of the resident's Electronic Health Record (EHR) showed no documentation of the edema. The facility's policy required all changes in resident condition to be communicated to the physician, but this was not followed, leading to the deficiency.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for two residents with indwelling urinary catheters, as observed during a survey. Resident 242, admitted with a diagnosis of sepsis, was found with their catheter bag and tube touching the floor on multiple occasions. During an observation, a Licensed Vocational Nurse (LVN) acknowledged that the catheter bag should not have been on the floor due to the risk of infection. Similarly, Resident 4, who has chronic kidney disease and a neurogenic bladder, was observed with their catheter bag and tube also touching the floor. A Certified Nurse Assistant (CNA) confirmed that it was their responsibility to ensure the catheter bag and tube were not on the floor to prevent infection. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the facility's staff were expected to keep catheter bags and tubes off the floor to avoid contamination and potential infections. The facility's policy on catheter care emphasized the importance of maintaining a clean technique and using a black bag to prevent the catheter from touching the floor. Despite these guidelines, the catheter bags and tubes for both residents were found on the floor, indicating a lapse in adherence to the facility's infection control procedures.
Failure in Timely IV Antibiotic Administration and PICC Line Care
Penalty
Summary
The facility failed to ensure timely administration of intravenous (IV) antibiotics for a resident with a peripherally inserted central catheter (PICC) line. The resident, admitted with osteomyelitis and methicillin-resistant staphylococcus aureus (MRSA), had an order for Cefazolin Sodium to be administered every 8 hours. However, the Medication Administration Record (MAR) showed multiple instances where the antibiotics were administered late, sometimes by several hours. The resident expressed concerns about the effectiveness of the treatment due to these delays, and it was noted that the registered nurses were inconsistent with the administration times. A specific incident involved a nurse who was not informed of the need to administer the medication, resulting in a delay because the antibiotic needed to be warmed to room temperature. The Director of Nursing (DON) acknowledged that the delay was unsafe and could affect the antibiotic's effectiveness. Additionally, the facility did not follow proper procedures during a PICC line dressing change for the same resident. The progress notes from the dressing change indicated the presence of blood clots and discoloration around the PICC line site, but did not include an arm circumference measurement. This measurement is crucial for identifying potential complications such as swelling or infection. The DON confirmed that the measurement was not documented and acknowledged its importance in assessing the resident's condition. The facility's policies and procedures for medication administration and central venous catheter care were not adhered to, contributing to these deficiencies. The medication administration policy requires medications to be given within 60 minutes of the scheduled time, and the central venous catheter care policy emphasizes the importance of measuring arm circumference during PICC line dressing changes. These lapses in following established protocols had the potential to compromise the resident's care and treatment outcomes.
Infection Control Lapses During Medication and Patient Care
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration and patient care. During a medication pass observation, a Licensed Vocational Nurse (LVN) was seen handling a potassium chloride capsule with bare hands, adding its contents to applesauce before administering it to a resident. The LVN confirmed not wearing gloves, believing it unnecessary unless the medication was hazardous. However, the Director of Nursing (DON) later clarified that gloves should be worn when handling medication capsules for infection control purposes. In another incident, a resident with a diagnosis of sepsis and a foley catheter was observed with their catheter bag touching the floor. An LVN, after touching the contaminated catheter bag with gloved hands, failed to remove the gloves or wash hands before adjusting the resident's nasal cannula and touching their shoulder. The LVN acknowledged the mistake, recognizing the potential for infection spread. The DON confirmed that the standard practice required changing gloves and washing hands after contact with contaminated areas. The facility's policies emphasized using standard precautions and maintaining clean techniques to prevent infections.
Failure to Prevent Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident was free from accidents, resulting in a fall and hip fracture. The resident, who had a history of cognitive deficit, multiple falls, fractures, muscle weakness, and neuropathy, was taken to the facility's patio by a Physical Therapy Aid (PTA) after finishing group physical therapy. The PTA did not inform the nurses or physical therapist about the resident's decision to go to the patio instead of her room and left the resident unattended. Subsequently, the resident fell on the patio and was found on the ground by the Rehabilitation Director (RD) and a nurse, who then transferred her to her room in a wheelchair. An X-ray confirmed that the resident had a hip fracture, and she was reported to be suffering from severe pain (10/10) following the incident. The resident's Minimum Data Set (MDS) indicated that she needed assistance for all activities and mobility, and her Fall Risk Assessment score was 13, indicating a high risk for falling. The facility's policy and procedure for the Fall Management System emphasized the commitment to providing an environment as free of accident hazards as possible. However, the failure to communicate and supervise the resident adequately led to the accident, resulting in the resident's hip fracture, pain, and subsequent hospitalization.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 743 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Danville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tice Valley Post Acute | 5.3 mi | ★★★★★ | 14 | 0 |
| Walnut Creek Skilled Nursing & Rehabilitation Cent | 5.4 mi | ★★★★★ | 4 | 0 |
| Rossmoor Post Acute | 5.4 mi | ★★★★★ | 4 | 0 |
| The Reutlinger Community | 5.7 mi | ★★★★★ | 2 | 0 |
| Tampico Healthcare Center | 6.7 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Danville Post-acute Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.