Goldwater Care Danville: Financial Exploitation - IL
The nurse, identified in inspection records only as V3, had worked the previous day from 6:00 AM to 6:30 PM. That morning, she had counted narcotics with the outgoing nurse and confirmed that a resident identified as R1 had two bottles of Ativan: one open in the medication cart, one sealed and stored in the refrigerator inside the locked medication room. There were two sheets in the narcotic book to match.
Before handing off her keys at the end of her shift, V3 asked to conduct a narcotic count with V6, an agency registered nurse who was taking over the east hall. V6 told her she was busy. No count happened.
When V3 returned the next morning and counted with the outgoing Licensed Practical Nurse V5, the refrigerator bottle was missing. So was its controlled substance form. When V3 asked V5 about the second bottle of Ativan, V5 became defensive. "What, don't do that to me," V5 said, according to V3's account to the Director of Nursing. V5 told her there had never been a second bottle and only one controlled substance form had ever been in the narcotic book.
The Director of Nursing confirmed to inspectors on November 25 that V3 reported the missing bottle on September 1. The facility replaced R1's Ativan that same day.
Federal inspectors, visiting on a complaint survey November 26, cited the incident under a deficiency tagged at minimal harm or potential for actual harm. By then, the facility said it had already retrained nursing staff, standardized communication with its pharmacy, and begun daily audits of medication carts and locked medication rooms.
What happened to the bottle between the evening of August 30 and the morning of August 31 — and who removed the form documenting it ever existed — the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Danville from 2025-11-26 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: June 20, 2026 · Our methodology
Goldwater Care Danville in DANVILLE, IL was cited for violations during a health inspection on November 26, 2025.
The nurse, identified in inspection records only as V3, had worked the previous day from 6:00 AM to 6:30 PM.
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.