The facility's medication error rate hit 10.7 percent after inspectors documented three errors in 28 medication opportunities. Federal regulations require nursing homes to keep error rates below 5 percent.
The problems centered on a resident identified as R11, who was prescribed 175 micrograms of Levothyroxine daily starting in July. But physician orders from September show the doctor temporarily increased the dose to 225 micrograms from September 11 through September 18, then returned it to 175 micrograms from September 19 through September 29.
Instead of following the temporary adjustment, nursing staff gave R11 both doses simultaneously.
From September 11 to September 18, R11 received 225 micrograms at 8:00 AM and another dose of Levothyroxine at 8:00 AM, totaling 450 micrograms daily. From September 19 to September 21, the resident got 175 micrograms at 6:00 AM and another 175 micrograms at 8:00 AM, totaling 400 micrograms daily.
The excessive thyroid medication coincided with abnormal lab results. On September 11, R11's Thyroid Stimulating Hormone level measured 0.26 micro-international units per milliliter, below the normal range of 0.34 to 4.82.
Nurse progress notes from September 21 confirm staff discovered R11 had "two Levothyroxine orders: 175 mcg and 225 mcg." The facility consulted its medical director, who ordered discontinuation of the 225 microgram dose and continuation of the 175 microgram daily dose.
The medication errors extended beyond thyroid medication. On September 21, registered nurse V10 administered incorrect doses of three different medications to R11: Sertraline 150 milligrams instead of the prescribed 175 milligrams, the wrong Levothyroxine dose, and Calcium 600 milligrams plus Vitamin D3 50 micrograms instead of the prescribed 20 micrograms of Vitamin D3.
When confronted about the errors at 11:00 AM that same day, V10 acknowledged the mistakes. "V10 stated she thought she had everything but made a few errors," inspection records show. "V10 also stated she would be more careful in the future."
Director of Nurses V2 told inspectors that "residents are expected to receive all of their prescribed medications as ordered." She added that "any medication not administered, whether due to error or omission, must be reported to the physician and the resident's family."
The facility's own medication administration policy requires a "triple check" system using five rights: right resident, right drug, right dose, right route, and right time. Staff are supposed to verify these elements when selecting the medication, when removing the dose from the container, and after preparing the dose before administration.
The policy states medications must be "administered in accordance with written orders of the prescriber" and requires checking "the label, container and contents for integrity and compared against the medication administration record."
Despite these written safeguards, the inspection found the facility failed to prevent multiple medication errors affecting the same resident over an extended period.
The September inspection was conducted in response to a complaint. Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" to residents.
R11's case illustrates how medication errors can compound over time when nursing staff fail to reconcile conflicting physician orders. The resident received excessive thyroid medication for nearly two weeks while laboratory results showed hormone levels already outside normal ranges.
The 10.7 percent medication error rate more than doubles the federal threshold designed to protect nursing home residents from preventable medication-related injuries. With 28 medication administration opportunities observed, the three documented errors suggest systemic problems with the facility's medication management processes.
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.