Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Hawthorne Inn Of Danville during CMS and state inspections, most recent first.
A resident with multiple pressure ulcers did not receive wound care in accordance with infection control protocols and physician orders. An RN failed to perform hand hygiene and change gloves between wound cleansing and dressing application, and a physician's order for a skin protectant was not entered into the EMR, resulting in missed treatment.
A resident admitted after CABG surgery did not have complete or accurate documentation of skin assessments, incisions, or bruising in their medical record. Nursing staff and the DON confirmed that the presence of incisions and bruising was not recorded at admission, despite being reported by the hospital. The facility's process for tracking and uploading provider notes and auditing records was not followed, resulting in incomplete documentation.
A resident admitted with multiple cardiac and neurological diagnoses did not have complete physician orders for key medications, as the orders lacked dosage, route, and administration times. The DON confirmed that these omissions were not identified or clarified at admission, contrary to facility policy requiring complete and clear medication orders.
A resident did not receive prescribed medications on time due to incomplete hospital discharge orders and delays in both order clarification and pharmacy delivery. Nursing staff did not promptly clarify medication orders lacking dosage and timing details, and the pharmacy did not provide the medications according to the intended start dates. Established procedures for obtaining medications outside regular hours were not followed, resulting in the resident missing several doses.
A resident admitted after a hospital stay for atrial flutter and electro-cardioversion experienced significant medication errors when incomplete discharge orders for Fosinopril, Metoprolol Succinate, and Mirtazapine were not promptly clarified by staff or providers. Delays in communication and pharmacy delivery led to multiple missed doses of these critical medications, as confirmed by MAR and staff interviews. Facility staff acknowledged the errors and contributing factors, including incomplete orders, delayed responses, and lack of backup pharmacy use.
A resident's medical records contained multiple inconsistencies, including conflicting documentation of code status between the POLST form and the Physician Order Sheet, incomplete provider signatures, and inaccurate progress notes regarding discharge status. Additionally, a nurse documented administration of a medication before it was delivered to the facility. These errors were confirmed by facility leadership and involved inaccurate and incomplete recordkeeping.
Two residents experienced unmanaged pain due to the facility's failure to consistently assess, document, and report pain to providers. One resident with spasticity and another with a recent hip fracture both had severe pain episodes that were not promptly addressed, resulting in missed therapy and decreased participation in daily activities. Pain assessments and follow-up documentation were incomplete, and provider notification was delayed, contrary to facility policy.
Several newly admitted residents did not receive prescribed medications as ordered due to unavailability, lack of follow-up with pharmacy or physician, and incomplete documentation. Nursing staff did not consistently check backup medication supplies or notify appropriate parties when medications were missing, and one resident's antibiotic order was incorrectly transcribed, leading to improper scheduling.
The facility did not follow its antibiotic stewardship policy and the McGreer Criteria for UTI diagnosis, resulting in antibiotics being prescribed and administered to several residents without proper documentation of symptoms or urine culture results. In some cases, antibiotics were started without confirming the presence of infection or reviewing culture findings, and required forms were not completed as per protocol.
A resident who was ambulating with a walker in the memory care unit was struck and knocked down by a door when a dietary aide opened it without first checking the blind spot mirror, as required. Staff interviews confirmed the mirror was intended to prevent such incidents, but it was not used at the time, resulting in the resident's fall.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 74 residents. The Dietary Manager admitted to not having the necessary qualifications, and the facility dietician only provided services one day per month. During the survey, the facility also failed to prevent cross-contamination of food and ice, did not date and label TCS food, and did not maintain sanitary food storage equipment.
The facility failed to prevent cross-contamination of stored food and ice, did not date and label TCS food, and did not maintain sanitary food storage equipment. Issues included a leaking walk-in freezer evaporator, an ice scoop stored in stagnant water, unlabeled cream cheese, a soiled can opener, and a dusty walk-in cooler evaporator. These conditions potentially affect all 74 residents.
The facility failed to timely complete MDS assessments for four residents, as required by their policy. The MDS/Care Plan Coordinator and the DON confirmed that the March MDS assessments for these residents were incomplete and not updated within the required timeframe.
The facility failed to timely transmit an MDS assessment for a resident due to the MDS/Care Plan Coordinator's unfamiliarity with completing the CAA section, resulting in a late submission.
The facility failed to ensure that two residents received the recommended and ordered amount of enteral feeding. Observations and interviews revealed that the feeding pumps were not consistently turned on, resulting in the residents not receiving the prescribed amounts on multiple days. Despite this, the residents did not appear dehydrated or malnourished, and there was no significant weight loss documented.
The facility failed to obtain a physician's order for oxygen administration and did not include the use of oxygen in the care plan for a resident with multiple diagnoses, including Alzheimer's Disease and Acute Upper Respiratory Infection. The resident was observed with oxygen administered via nasal cannula without a specified order for liter flow or type of administration.
The facility failed to accurately assess and document side rail use for two residents, including obtaining consent and documenting alternative interventions. The assessments were incomplete and inaccurate, and the care plans did not include side rail use.
The facility failed to complete quarterly psychotropic medication assessments, document specific behaviors and nonpharmacological interventions, include a duration for PRN psychotropic medication orders, obtain consent for psychotropic medication use, and rule out underlying causes of behaviors for three residents. These deficiencies were identified through medical record reviews and staff interviews, revealing significant lapses in adherence to the facility's policies.
A resident with a history of UTIs was prescribed Cipro without obtaining a culture to ensure the appropriate antibiotic was used. Despite a urine dip test and labs being drawn, no urinalysis or culture and sensitivity test was ordered. The resident required another course of antibiotics less than 30 days after the final dose of Cipro.
The facility failed to offer and administer the pneumonia vaccine as recommended for two residents. One resident with Cerebral Palsy did not receive the required PCV15 or PCV20 vaccine, and another resident did not receive the necessary PCV15 or PCV20 vaccine despite multiple attempts to obtain consent. The RN/Infection Preventionist did not document these attempts and was initially unaware of the vaccination requirements.
Failure to Prevent Cross Contamination and Implement Wound Care Orders
Penalty
Summary
The facility failed to prevent cross contamination during wound care and did not implement physician-ordered pressure ulcer treatments for one resident with multiple wounds. Specifically, a registered nurse (RN) did not perform hand hygiene or change gloves after cleansing a resident's sacral wound and before applying a clean dressing, contrary to the facility's wound care policy and standard infection control practices. The RN believed that hand hygiene and glove changes were only necessary after removing soiled dressings, not after wound cleansing. This lapse was observed during a wound treatment procedure and confirmed by the RN involved. Additionally, the facility did not ensure that all physician orders for wound care were entered into the resident's electronic medical record (EMR). A wound physician had ordered a skin protectant for the resident's heels, but this order was not entered into the EMR prior to a certain date, resulting in the treatment not being administered as prescribed. The resident had a history of an unstageable pressure ulcer of the coccyx, a deep tissue injury to the right heel, and a stage four sacral pressure ulcer. Staff interviews and record reviews confirmed that the required interventions were not consistently implemented according to physician orders and facility policy.
Incomplete and Inaccurate Medical Record Documentation for New Admission
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident who was admitted following a coronary artery bypass grafting (CABG). Upon admission, nursing notes did not document an assessment of the resident's skin or indicate the presence of any skin issues or bruising. Although the admission observation stated there were no alterations in the resident's skin, a subsequent skin assessment several days later noted incisions and bruising, but did not specify the location of the bruising. There was no documentation in the nursing notes between admission and the later assessment that referenced any bruising. Interviews with nursing staff revealed that the resident was admitted with closed incisions and bruising, which had been reported by the hospital prior to admission. However, the facility's admission assessments, skin assessments, and notes did not document the presence of incisions or bruising at the time of admission. The Director of Nursing confirmed the lack of documentation and was in the process of obtaining provider progress notes to verify the resident's condition upon admission. The facility's job description for medical records staff includes responsibilities for tracking and uploading physician notes and auditing records for discrepancies, which was not adequately performed in this case.
Failure to Obtain Complete Physician Orders for Medications on Admission
Penalty
Summary
The facility failed to obtain complete and clarified physician orders for medications at the time of admission for a resident with multiple complex diagnoses, including paroxysmal atrial fibrillation, atrial flutter, cardiac murmur, hypertension, Alzheimer's disease, and various vitamin deficiencies. Upon admission from a local hospital following a cardioversion procedure for atrial flutter with rapid ventricular rate, the resident's discharge medication list included Metoprolol Succinate, Mirtazapine, and Fosinopril. However, the orders for these medications were incomplete, lacking essential details such as dosage, route, and time of administration, with instructions simply stating "See instructions" and no further clarification provided. The Director of Nursing confirmed that these medication orders were not clarified upon the resident's admission, acknowledging that this oversight should have been identified during the nurse's confirmation of orders. Facility policy requires that all physician medication orders be complete, including the date, medication name, dosage, route, time of administration, and, if appropriate, the duration of therapy. The policy also mandates that all new orders be promptly communicated to the pharmacy. The failure to clarify and obtain complete medication orders on admission resulted in a deficiency in meeting the immediate care needs of the resident.
Delayed Medication Delivery Due to Incomplete Orders and Pharmacy Process Failures
Penalty
Summary
The facility failed to provide pharmaceutical services in a timely manner for one resident, as evidenced by repeated delays in the delivery and administration of prescribed medications following hospital discharge. Upon admission, the resident had incomplete physician orders for Fosinopril, Metoprolol Succinate, and Mirtazapine, with instructions listed as 'See instructions' and lacking specific dosage, route, or administration times. Facility staff did not clarify these orders promptly, resulting in delays in both order clarification and medication delivery. The pharmacy did not provide the medications according to the start dates indicated in the clarified physician orders, with Fosinopril not available until several days after the intended start date, and similar delays for Metoprolol Succinate and Mirtazapine. Documentation shows that staff signed off on medication deliveries days after the orders were clarified and after the medications were due to be administered. Interviews and record reviews revealed that both nursing staff and pharmacy personnel failed to follow established procedures for obtaining and delivering medications, especially outside of regular pharmacy hours. The facility's corporate nurse consultant acknowledged that staff did not clarify the incomplete hospital discharge orders in a timely manner and did not utilize the pharmacy's after-hours process to obtain urgently needed medications. The pharmacy's hours of operation and procedures for STAT orders were not effectively followed, contributing to the delay in providing necessary medications to the resident.
Failure to Prevent Significant Medication Errors Due to Delayed Order Clarification and Pharmacy Delivery
Penalty
Summary
The facility failed to prevent significant medication errors for a resident admitted after a hospital stay for atrial flutter and electro-cardioversion. Upon admission, the resident's hospital discharge medication orders for Fosinopril, Metoprolol Succinate, and Mirtazapine were incomplete, lacking clear instructions for dosage, route, or administration times. The facility did not promptly clarify these orders with the prescribing providers, resulting in delays in obtaining and administering the medications. Communication between facility nurses and providers was delayed, with significant gaps in response times documented in the electronic messaging system. As a result of these delays, the resident missed multiple doses of critical medications, including six doses of Fosinopril, one dose of Metoprolol Succinate, and three doses of Mirtazapine. The Medication Administration Record (MAR) and pharmacy delivery records confirmed that these medications were not available or not administered as ordered during the initial days following admission. The errors were attributed to incomplete hospital discharge orders, delayed clarification by facility staff and providers, and delays in pharmacy delivery, including the lack of use of backup pharmacy services. Interviews with facility staff, including the DON, Nurse Practitioner, and Corporate Nurse Consultant, confirmed the sequence of events and acknowledged the significance of the medication errors. The family member of the resident also expressed concerns about the lack of timely medication administration. The facility's own Medication Error Report documented the delay in starting the medications and the contributing factors, with staff acknowledging that the errors were significant.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, resulting in multiple inconsistencies and errors. The resident's code status was documented inconsistently across various records: the admission observations and face sheet listed the resident as Full Code, while the POLST form, signed by the resident, indicated Do Not Attempt Resuscitation (DNAR). The POLST form was not signed by a provider until 13 days after the resident's admission, and after the resident had already been transferred to the hospital. The Physician Order Sheet (POS) continued to list the resident as Full Code, which conflicted with the POLST. The Director of Nursing and Resident Service Director confirmed these discrepancies and acknowledged that the POLST and POS were incongruent and incomplete at the time of the resident's transfer to the hospital. Additional documentation errors were identified in the resident's progress notes. The Social Service Director documented that the resident was discharged home from the hospital, which was inaccurate, as the resident had expired in the hospital. The Social Service Director admitted to not verifying this information with the family before documenting it. Furthermore, the Medication Administration Record (MAR) indicated that a nurse had administered Fosinopril to the resident before the medication had been delivered to the facility, which was confirmed by pharmacy delivery records and the Director of Nursing. The nurse acknowledged that the medication could not have been administered as documented. These findings demonstrate failures in maintaining accurate and complete medical records for the resident.
Failure to Provide Effective Pain Management and Timely Provider Notification
Penalty
Summary
The facility failed to provide effective pain management, assess for pain, and report pain to the provider for two residents who required such services. For one resident with a history of stroke and right-sided spasticity, there were multiple documented instances of severe pain, including pain rated as high as 10 out of 10, facial grimacing, moaning, missed therapy sessions, and refusal to eat. Despite these clear signs of uncontrolled pain, there was no documentation that the provider was notified of the resident's increased pain until several days after the onset of symptoms. Pain assessments were inconsistently documented, and follow-up pain ratings after administration of PRN pain medications were not recorded, only noting whether the medication was effective. The resident's care plan included pain management as needed, but the interventions were not adequately implemented or communicated among staff, and therapy staff reported pain to nursing without evidence of timely provider notification or care plan adjustment. Another resident admitted for therapy following a left hip fracture did not receive a comprehensive pain assessment upon admission. The initial assessment only asked if the resident was experiencing pain at that moment and did not prompt further questions about pain history or potential for pain related to the hip fracture. The resident reported significant pain (rated 8 out of 10) on the first night, but no pain medication was ordered until the following day. Nursing staff did not report the resident's pain to the provider on the day of admission, resulting in a delay in pain management. The comprehensive pain assessment was not completed until seven days after admission, and follow-up pain ratings after PRN medication administration were not documented. The facility's pain management policy required pain assessments on admission, quarterly, with significant changes, and every shift, with provider notification as needed. However, these procedures were not followed for the two residents, leading to unmanaged pain, missed therapy, and decreased participation in activities of daily living. Staff interviews confirmed gaps in communication, documentation, and timely provider notification regarding residents' pain.
Failure to Provide Timely and Accurate Medication Administration for New Admissions
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for four newly admitted residents. In multiple instances, prescribed medications such as Latanoprost, Rosuvastatin, Trazodone, Triamcinolone, Clarithromycin, Amitriptyline, Aspirin, Metoprolol, Levofloxacin, and Atorvastatin were not given because they were not available at the time of administration. Facility policy required that medications be transcribed accurately and administered as ordered, and that backup medication supplies be checked and pharmacy, physician, and family be notified if medications were unavailable. However, these steps were not consistently followed. For each affected resident, there was a lack of documentation indicating that the pharmacy or physician had been notified about the unavailability of medications or missed doses. Nursing staff acknowledged that they did not always follow up with the pharmacy or physician, and in some cases, they were unsure if they had taken any action regarding the missed medications. Additionally, there was no evidence that medications were obtained from the backup supply when unavailable, and required documentation in nursing notes was missing. One resident's hospital discharge order for Levofloxacin was incorrectly transcribed, resulting in the medication being scheduled at the wrong interval. The Director of Nursing confirmed that the backup medication safe was not used to obtain the missing medications and that required notifications and documentation were not completed. These failures resulted in residents not receiving their prescribed medications as ordered upon admission.
Failure to Implement Antibiotic Stewardship and UTI Criteria
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required by its own policy and the McGreer Criteria for infection surveillance. Specifically, the facility did not ensure that symptoms met the criteria for urinary tract infection (UTI) and did not consistently obtain or review urine cultures before initiating antibiotic treatment for four out of six residents reviewed for antibiotic stewardship. The policy required tracking antibiotic use daily and using the McGreer Criteria to guide UTI diagnosis and treatment, including documentation of symptoms and microbiological evidence. For several residents, antibiotics were prescribed and administered without adequate documentation of symptoms or urine culture results. One resident was treated with Ciprofloxacin for UTI symptoms, but no urine culture was obtained, and there was no documentation of a McGreer form. Another resident received two courses of antibiotics for UTI, but there were no recorded symptoms for one course, and the urine culture showed mixed flora without a repeat culture. A third resident was treated with Nitrofurantoin despite a urine culture indicating resistance to this antibiotic, and there was no evidence that the culture results were reviewed or that follow-up with a physician occurred. In another case, a resident received antibiotics for UTI, but the urine culture was only obtained later and not reviewed during treatment. Interviews with facility staff confirmed that infection control logs did not consistently document symptoms or urine cultures for the affected residents. The Infection Preventionist and Director of Nursing acknowledged that required documentation, including completion of the McGreer form and review of culture results, was missing in several cases. The staff also confirmed that antibiotics were sometimes started based on family requests or preliminary urine dipstick results, without following the full protocol for confirming UTI diagnosis and appropriate antibiotic use.
Failure to Use Blind Spot Mirror Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to utilize a blind spot mirror before opening a set of double doors, resulting in a fall for a resident. The resident, who was admitted for skilled nursing and rehabilitation, was observed ambulating with a four-wheeled walker in the memory care unit. According to the fall investigation report, the resident was walking near the front door when a dietary aide opened the door, which struck the resident and caused her to lose balance and fall. A certified nursing assistant witnessed the incident and confirmed that the aide did not see the resident due to a blind spot. Interviews with staff revealed that a blind spot mirror was installed on the wall to allow visibility of the other side of the door before opening it. The dietary aide involved in the incident acknowledged that she should have checked the mirror prior to opening the door. The administrator confirmed that staff are expected to use the mirror to prevent such accidents, but in this instance, the procedure was not followed, directly leading to the resident's fall.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 74 residents. On 4/15/2024, the Dietary Manager (V16) was observed supervising dietary operations but admitted to not being a clinically qualified Certified Dietary Manager or having equivalent training. V16 also reported that the facility dietician only provides services one day per month. V16 confirmed not meeting the State of Illinois standards for a food service manager or dietary manager and lacked the necessary qualifications and experience required for the position. Throughout the survey from 4/15/2024 to 4/17/2024, 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 deficiencies were observed in the facility's kitchen and food storage areas, indicating a lack of proper food safety and sanitation practices. The facility's Long-Term Care Facility Application for Medicare and Medicaid documented that 74 residents reside in the facility.
Food Storage and Sanitation Deficiencies
Penalty
Summary
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. Specifically, the kitchen walk-in freezer evaporator cooling unit was leaking condensate into a plastic bin, which overflowed onto shelving beneath it, exposing numerous boxes of food items, including an open box of cookies, to the leaked condensate. This leak had been present for three years according to the Dietary Manager. Additionally, an ice scoop was stored in stagnant water containing debris, and a package of cream cheese in the kitchen reach-in cooler was not labeled with a date or time opened or a use-by date. The kitchen can opener was soiled with metal shavings and food debris, and the kitchen walk-in cooler evaporator cooling unit was excessively soiled with dust, covering the entire front surface and fan guards. These deficiencies were observed over multiple days, with the Dietary Manager acknowledging the issues and taking some immediate actions such as discarding the unlabeled cream cheese and requesting staff to clean the can opener. The facility's Long-Term Care Facility Application for Medicare and Medicaid documents that 74 residents reside in the facility, all of whom could potentially be affected by these unsanitary conditions.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to timely complete Minimum Data Set (MDS) assessments for four residents (R4, R44, R49, R58) out of 18 reviewed in a sample of 36. The facility's policy requires quarterly MDS assessments to be completed at least every three months, with the MDS Coordinator responsible for ensuring their completion and weekly transmission. However, the MDS assessments for R49, R4, R44, and R58 were found to be incomplete and not updated within the required timeframe. Interviews with the MDS/Care Plan Coordinator and the Director of Nursing confirmed that the March MDS assessments for these residents had not been completed timely, with the last completed MDS assessments for these residents dating back to earlier months.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to timely transmit a Minimum Data Set (MDS) assessment for one of 18 residents reviewed for MDS assessments in the sample list of 36. The facility's MDS Completion policy requires the MDS Coordinator to ensure completion and transmission of MDS assessments at least weekly, with comprehensive assessments transmitted within 14 days of the Care Plan completion date. However, the electronic medical record for the resident indicated that the Annual MDS was completed but not submitted. The MDS/Care Plan Coordinator admitted that the MDS had not been submitted because they were unfamiliar with how to complete the Care Area Assessment (CAA) section of the MDS, confirming that the MDS would be submitted late.
Failure to Administer Ordered Enteral Feeding Amounts
Penalty
Summary
The facility failed to ensure that two residents received the recommended and ordered amount of enteral feeding. For Resident 53, the care plan included diagnoses such as traumatic brain injury, aphasia, spastic hemiplegia, encephalopathy, gastro-esophageal reflux disease, and dysphagia. The physician's order specified that the resident should receive 1890 ml of Fibersource HN per day. However, observations on multiple occasions revealed that the feeding pump was not turned on, and the resident did not receive the ordered amount of feeding on 12 out of 16 days reviewed. Despite these deficiencies, the resident did not appear dehydrated or malnourished, and there was no significant weight loss documented over the past six months. For Resident 11, who had diagnoses including multiple sclerosis and dysphagia, the physician's order specified that the resident should receive 1900 ml of Fibersource per day. Observations and interviews indicated that the resident did not receive the ordered amount of feeding on 13 out of 16 days reviewed. The resident communicated that there were no concerns regarding the feedings and did not appear dehydrated or malnourished. The resident's weight fluctuated but did not show any significant weight loss or gain over the past six months. The Director of Nursing confirmed that both residents were not receiving the ordered amount of feeding via their G-tubes. The facility's failure to administer the prescribed enteral feeding amounts as ordered by the physician constitutes a deficiency in care, as documented by the surveyors.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration and did not include the use of oxygen in the care plan for a resident. The resident had diagnoses including Alzheimer's Disease with Late Onset, Anxiety Disorder, Acute Upper Respiratory Infection, Cough, and Wheezing. Despite an order to change oxygen tubing and humidification bottle weekly, there was no order specifying the amount of liter flow or the type of administration (nasal cannula or mask). The resident was observed in bed with oxygen administered via nasal cannula, but the oxygen setting was not visible. The Director of Nursing confirmed that nurses can start oxygen as a nursing measure but must obtain a doctor's order, which was not present in the resident's electronic medical record.
Failure to Accurately Assess and Document Side Rail Use
Penalty
Summary
The facility failed to accurately and routinely assess side rail use per its policy, obtain consent for side rail use, document alternative interventions attempted prior to use, and care plan for side rails for two residents. One resident had a half-length side rail in the upright position on one side of the bed, but the resident stated they did not really use the railing. The resident's medical records showed moderate cognitive impairment and independence in bed mobility, but the side rail assessment was incomplete and inaccurate, and there was no documented consent for side rail use. Additionally, the resident's care plan did not document side rail use, and the CNAs were unsure about the side rail's usage and duration on the bed. The Director of Nursing confirmed the assessment's inaccuracies and lack of consent documentation, and the MDS/Care Plan Coordinator confirmed the care plan did not include side rail use. Another resident was observed with half side rails in the upright position on both sides of the bed and stated they used the side rails to assist with turning in bed and to prevent falling out. The resident's medical records showed moderate cognitive impairment and substantial assistance required for bed mobility, but the side rail assessment was incomplete and inaccurate. The assessment inaccurately documented the resident's safety awareness and bed mobility, and there was no documented consent for side rail use. The Director of Nursing and the MDS/Care Plan Coordinator confirmed the assessment's inaccuracies and the care plan's lack of documentation for side rail use. The Director of Nursing stated that side rail assessments are done upon admission and annually, but was unaware that the facility's policy required re-evaluation every 90 days. The assessments were supposed to be completed by the floor nurse, who should observe the resident's use of the side rail, review medication use, and document prior alternative interventions used. The Director of Nursing confirmed the assessments were incomplete and inaccurate, and the care plans did not include side rail use for the residents in question.
Failure to Adhere to Psychotropic Medication Policies
Penalty
Summary
The facility failed to complete quarterly psychotropic medication assessments, identify and document specific targeted behaviors and nonpharmacological interventions, include a duration for PRN psychotropic medication orders, obtain and document consent for psychotropic medication use, and rule out underlying causes of behaviors prior to initiating psychotropic medications for three residents. These deficiencies were identified during a review of the medical records and interviews with staff members, revealing significant lapses in the facility's adherence to its own Psychopharmacologic Drug Usage Procedure dated 10/18/17. One resident, who had moderate cognitive impairment and exhibited delusions and verbal behaviors, had their Seroquel dosage increased without documentation of nonpharmacological interventions being attempted first. The resident's care plan and behavior tracking forms did not accurately reflect the specific behaviors related to delusions about their spouse and stolen items. Additionally, the facility did not conduct psychotropic medication assessments quarterly as required, with a significant gap between assessments. Another resident was prescribed alprazolam and venlafaxine without the required 14-day limitation for PRN orders and without documented consent for the psychotropic medications. A third resident, admitted for therapy following a surgical hip fracture repair, was started on Risperidone without prior behavioral tracking or documentation of delusional behaviors. The facility also failed to investigate the root cause of the resident's aggressive behaviors during perineal care, which were likely related to pain from the surgical site. The facility's Director of Nursing acknowledged these deficiencies and the lack of adherence to the facility's policies and procedures.
Failure to Obtain Culture for Antibiotic Stewardship
Penalty
Summary
The facility failed to obtain a culture to ensure the appropriate antibiotic was being used for a resident with a history of urinary tract infections. On 2/28/24, the resident was noted to be sleeping more than usual, and a urine dip test was performed. However, when labs were drawn on 2/29/24, neither a urinalysis nor a culture and sensitivity test was ordered. Despite this, Cipro 500 milligrams was prescribed and administered twice daily for ten days starting on 2/29/24. The Director of Nursing later confirmed that a culture should have been done to ensure the correct antibiotic was given. Less than 30 days after the final dose of Cipro, the resident had another urinary tract infection that required antibiotics.
Failure to Administer Pneumonia Vaccines as Recommended
Penalty
Summary
The facility failed to offer and administer the pneumonia vaccine as recommended for two residents. The facility's policy, revised on 8/11/22, mandates that all residents aged 65 years or more, and those at high risk, be offered the Pneumococcal vaccine according to CDC guidelines. However, the facility did not adhere to this policy for two residents. Resident R21, who has a diagnosis of Cerebral Palsy and is 65 years old, received a PPSV23 vaccine on 3/9/20 but did not receive the required PCV15 or PCV20 to be up to date. Similarly, Resident R48, who is also 65 years old, received a PPSV23 on 12/9/15 but did not receive the necessary PCV15 or PCV20 vaccine. The Registered Nurse/Infection Preventionist (V9) admitted to not documenting attempts to obtain consent from R48 for the pneumonia vaccine, despite multiple attempts. Additionally, V9 was initially unaware that R21 was due for another vaccine until reviewing the guidelines. These lapses in following the facility's vaccination policy and CDC recommendations led to the deficiency in providing appropriate immunizations to the residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 84 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — 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
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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) |
|---|---|---|---|---|
| La Bella Of Danville | 1.8 mi | ★★★★★ | 16 | 3 |
| Accolade Healthcare Danville | 3.1 mi | ★★★★★ | 7 | 0 |
| Goldwater Care Danville | 4 mi | ★★★★★ | 8 | 1 |
| Waters Of Covington, The | 13.1 mi | ★★★★★ | 27 | 2 |
| Williamsport Nursing And Rehabilitation | 18.8 mi | ★★★★★ | 0 | 0 |
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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.