Goldwater Care Danville: Immediate Jeopardy Wound Care - IL
The wound was already growing MRSA.
The incident triggered an immediate jeopardy finding at Goldwater Care Danville, the most serious designation federal inspectors can assign, reserved for situations where a facility's failures have placed residents in immediate risk of serious harm or death. The inspection was completed October 2, 2025.
The resident, identified in inspection records as R13, had a Stage 4 pressure ulcer on the right medial great toe, first documented on April 1, 2025. Stage 4 is the deepest classification for pressure wounds, extending through skin and tissue to muscle or bone. At initial evaluation, the wound measured 1.3 centimeters long, 1.0 centimeter wide, and 0.2 centimeters deep, with thick adherent devitalized tissue and moderate drainage.
By September 17, the wound had worsened. A wound evaluation that day described the ulcer as exacerbated due to infection, now deeper at 0.5 centimeters. A culture taken the same day came back positive for Methicillin-Resistant Staphylococcus Aureus, the antibiotic-resistant bacterial infection that kills tens of thousands of Americans each year and is notoriously difficult to eradicate once it takes hold in open tissue.
A week later, inspectors watched what happened next.
On September 30 at 3:00 PM, Wound Physician V13 and Registered Nurse V23 performed wound care on R13's toe. The old dressing had adhered to the wound and had to be soaked off with normal saline. Once removed, the ulcer was visible, dime-sized, covered in thick yellow slough. V13 debrided it, revealing a red wound bed beneath.
V23 did not change her gloves. She did not perform hand hygiene. She went directly from removing the contaminated dressing to applying the new one.
At 3:20 PM, she told inspectors she forgot.
The facility's own Director of Nursing, identified as V2, confirmed the next day what the lapse meant. Cross-contaminating an open pressure ulcer can allow bacteria to enter the wound and cause infection, she said. She confirmed that R13's infected Stage 4 ulcer was facility-acquired and could have been prevented. She also confirmed that no risk management assessment had ever been completed for R13's wound, a basic step in tracking how serious pressure injuries develop and whether the facility bears responsibility for them.
The wound physician, V13, offered a separate account of how the ulcer formed in the first place. Speaking to inspectors on September 30, V13 said the injury was caused by the inside of R13's shoe, where overlapping material had rubbed against the toe. V13 said they had cut a hole in the side of the shoe to relieve pressure, though V13 did not specify when that modification was made, only that it happened months ago.
The shoe had been cutting into the resident's foot long enough for a Stage 4 wound to develop, become infected, and grow MRSA before the hole was cut.
The inspection also captured concerns beyond R13's case. A nurse practitioner identified as V21 told inspectors on September 26 that two other residents, R2 and R4, were completely dependent on staff for all care and severely cognitively impaired. V21 described the minimum standard of care those residents required: repositioning and incontinence care at least every two hours, proper nutrition, thorough admission assessments, and weekly skin checks. The inspection report cuts off before V21's full statement is recorded, leaving the outcome for R2 and R4 incomplete in the available record.
What is complete is the picture of R13: a wound that started from a shoe, deepened over months, became infected with a dangerous drug-resistant bacterium, and was then handled by a nurse who contaminated it with her own gloves. The Director of Nursing was not in her role when the ulcer first developed and said she could not speak to how it was acquired. Nobody at the facility had completed a risk assessment to answer that question.
The wound physician had cut a hole in the shoe.
The nurse had forgotten to change her gloves.
The resident's infected toe remained open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Danville from 2025-10-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Goldwater Care Danville in DANVILLE, IL was cited for immediate jeopardy violations during a health inspection on October 2, 2025.
The wound was already growing MRSA.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.