Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Danville Regional Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment but alertness and orientation during the day was not allowed to fully participate in decisions regarding his advance directive and code status. Despite being his own responsible party and able to communicate his wishes, decisions about his care were made by his son without documented physician determination of incapacity, and required sections of the POA document were left incomplete. Facility policy requiring resident participation and physician assessment of capacity was not followed.
Surveyors identified that two residents had inaccurate MDS coding: one resident with a suprapubic catheter was not coded for catheter use despite relevant orders and care plans, and another resident was incorrectly coded as receiving an anticoagulant medication when none was prescribed.
A resident with multiple disabilities was repeatedly observed with a slack and severely frayed wheelchair seat belt that was not repaired or replaced, despite staff awareness. Documentation and care planning failed to specify the type of seat belt or include parameters for ongoing assessment, and required quarterly reviews of adaptive devices were not completed.
Surveyors found that topical creams, oral medications, and controlled drugs were not properly separated in medication carts, with wound gel stored next to eye drops and throat lozenges, and nitroglycerin tablets stored with eye drops. Insulin pens for two residents were not properly dated, and one cart contained approximately 50 loose pills. These issues were confirmed by two LPNs and were not in accordance with the facility's medication storage policy.
The facility failed to ensure proper catheter care and documentation for two residents, resulting in a UTI for one resident and improper catheter insertion for another. The urinary catheter bag and tubing of one resident were observed on the floor, and both residents' records lacked documentation of a diagnosis of urinary retention.
The facility failed to ensure a treatment cart remained locked, making medications accessible to residents and visitors. An LPN confirmed the cart should not have been unlocked, and the DON noted that two residents with severe cognitive impairments wandered the building. The facility's policy specifies that only authorized staff should have access to medication storage areas.
Failure to Honor Resident's Right to Formulate Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored. The resident in question was admitted without Power of Attorney (POA) or guardianship documentation and was listed as his own responsible party. Despite being moderately cognitively impaired, he was alert and oriented for much of the day, as confirmed by staff and social service notes. The resident's medical record showed that he was able to participate in meaningful conversations and expressed a desire to get better, indicating an understanding of his condition and the ability to make his own healthcare decisions. Documentation revealed that a notary was scheduled to assist the resident in establishing a healthcare POA, and discussions about changing his code status were held with his son. The Medical Power of Attorney document was signed by both the resident and his son, but the section regarding when the agent's authority would become effective was left blank and not initialed by the resident. The POST form, which outlined the resident's code status, was signed by the son rather than the resident, and there was no documentation from a physician determining that the resident was incompetent to make his own decisions at that time. Interviews with staff and documentation in the medical record indicated that the resident was capable of making his own healthcare decisions, particularly during the day. However, decisions regarding his code status and comfort measures were made by his son without clear evidence that the resident was unable to participate or that a physician had declared him incompetent. Facility policy requires that residents make their own decisions if they have capacity, and that a physician's assessment of incapacity be documented before a representative or POA acts on their behalf. This process was not followed, resulting in a failure to honor the resident's right to formulate and participate in decisions regarding advance directives.
Inaccurate MDS Coding for Catheter Use and Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents. For one resident with diagnoses including dementia, hypertension, anxiety, and high cholesterol, the MDS did not reflect the presence of a suprapubic catheter, despite medical orders and care plans indicating its use and the need for related care. Documentation showed ongoing orders for catheter management and care plans addressing toileting assistance and fall risk related to the catheter tubing, but this was not captured in the MDS coding. For another resident with multiple sclerosis, depression, and weakness, the MDS was incorrectly coded to indicate the use of an anticoagulant medication, although there was no prescription for such medication. The error was attributed to the MDS coordinator inadvertently coding the wrong medication type. These inaccuracies were identified through record reviews, observations, and interviews during the survey.
Failure to Maintain and Monitor Wheelchair Seat Belt for Resident
Penalty
Summary
A deficiency was identified when a resident who required a seat belt in his wheelchair was observed multiple times with a seat belt that was slack, improperly positioned, and frayed nearly in half due to rubbing against a sharp edge of the wheelchair frame. Despite repeated observations over several days, the seat belt remained in poor condition and was not replaced or repaired. The resident, who had diagnoses including cerebral palsy, shaken infant syndrome, and intellectual disabilities, was able to unbuckle the seat belt but could not re-buckle it independently. Staff, including the Social Service Director and Maintenance Staff, acknowledged the poor condition of the belt during observations. Review of the resident's medical record showed an initial adaptive device review and a physician's order for a wheelchair with a seat belt, but neither specified the type of belt or included parameters for ongoing assessment of its placement, appropriateness, or condition. The care plan also lacked details regarding the type of belt and did not address ongoing monitoring or assessment. Facility policy required quarterly review of adaptive devices by the IDT team and inclusion of device use in the care plan, but these requirements were not met for this resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's medication management practices. On one medication cart, wound gel was stored next to eye drops and throat lozenges, and an insulin pen for a resident was present without a date indicating when it was opened. Additionally, approximately 50 loose pills were found in a drawer of the same cart. On another medication cart, nitroglycerin tablets were stored with eye drops, and an insulin pen for another resident was found with an expiration date. These observations were confirmed by two LPNs. The facility's policy requires topical medications to be stored separately from oral medications when infection control is a concern and mandates that expired, contaminated, or deteriorated medications be separated from others until disposal or return to the pharmacy.
Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, resulting in a urinary tract infection (UTI). Resident 81's urinary Foley bag and catheter tubing were observed on the floor, which is against the care plan that specified the tubing should not touch the floor. The resident developed a UTI with symptoms including acute change in mental status and suprapubic pain, and was placed on antibiotic therapy. Additionally, the resident's record lacked documentation of a diagnosis of urinary retention, which was the reason given for the catheter insertion. This discrepancy was confirmed through interviews and record reviews. Another resident, Resident 155, also had a Foley catheter inserted without proper documentation of a diagnosis of urinary retention. The resident's wife reported that the catheter was inserted due to abdominal distention and excessive urine retention. The resident's record indicated a high post-void residual (PVR) and subsequent catheterization, but lacked a formal diagnosis of urinary retention. The facility's policy on indwelling urinary catheters requires an assessment to include the reason for the catheter, which was not documented in these cases.
Unlocked Treatment Cart with Accessible Medications
Penalty
Summary
The facility failed to ensure that one of four treatment carts remained locked, making medication accessible to residents and visitors. On 4/30/24 at 9:48 a.m., the Rosewood treatment cart was observed unlocked, containing prescription medications for Residents 345, 11, 79, and 63. Several staff members passed by the unlocked cart without securing it. LPN 5 confirmed that the cart should not have been unlocked and subsequently locked it. The Moving Forward Unit Manager indicated that all treatment carts should be locked to prevent unauthorized access. The Director of Nursing noted that two residents with severe cognitive impairments wandered the building. The facility's policy on medication storage, dated 7/21/22, specifies that only authorized staff should have access to medication storage areas.
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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.
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Nursing homes near Danville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avon Health & Rehabilitation Center | 2.5 mi | ★★★★★ | 5 | 0 |
| Majestic Care Of Avon | 3.6 mi | ★★★★★ | 18 | 0 |
| Countryside Meadows | 6.4 mi | ★★★★★ | 15 | 0 |
| Brownsburg Meadows | 7.2 mi | ★★★★★ | 4 | 0 |
| Brownsburg Health Care Center | 7.8 mi | ★★★★★ | 42 | 1 |
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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.