Goldwater Care Danville

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R13's Stage 4 pressure ulcer.Resident R13's Wound Evaluation and Management Summary - Initial Evaluation dated 4/1/25 documents the Stage 4 pressure ulcer on the right, distal, medial foot as having 30% thick adherent devitalized tissue, moderate serous drainage, and measuring 1.3 cm long by 1.0 cm wide by 0.2 cm deep.A subsequent Wound Evaluation and Management Summary dated 9/17/25 documents the same ulcer as exacerbated due to infection and measuring 0.7 cm long by 1.0 cm wide by 0.5 cm deep, with signs of infection.Another Wound Evaluation and Management Summary, dated 9/24/25, documents that a wound culture was obtained via deep swab on 9/17/25 and the results revealed Methicillin-Resistant Staphylococcus Aureus (MRSA).On 9/30/25 at 3:00 PM, V13 (Wound Physician) and V23 (Registered Nurse) completed wound care for Resident R13's right medial great toe Stage 4 pressure ulcer. RN V23 did not change gloves or perform hand hygiene after removing Resident R13's dressing and prior to applying a clean dressing.The old dressing was adhered to the wound, requiring V23 to soak it off with normal saline. The ulcer appeared dime-sized with a thick, dry, yellow slough covering it before V13 debrided the wound, revealing a red wound bed.At 3:20 PM on the same day, RN V23 admitted she forgot to change gloves or perform hand hygiene between removing and reapplying the dressing.At 2:55 PM on 9/30/25, Wound Physician V13 stated that Resident R13's right medial great toe Stage 4 pressure ulcer was caused by the inside of Resident R13's shoe, which had overlapping material that rubbed against the toe. V13 stated that they had cut a hole

in the side of Resident R13's shoe to relieve pressure months ago.On 10/1/25 at 2:00 PM, DON V2 stated that facility nurses are expected to change gloves and perform hand hygiene after removing a soiled dressing and prior to applying a new one. V2 DON stated she was not in her role at the time Resident R13 developed the pressure ulcer and therefore could not speak to how it was acquired. She also confirmed that a risk management assessment was not completed for Resident R13's ulcer.V2 DON stated that cross-contaminating an open pressure ulcer can allow bacteria to enter the wound and cause an infection. She confirmed that Resident R13's infected Stage 4 pressure ulcer on the right great toe was facility-acquired and could have been prevented.On 9/26/25 at 11:00 AM, Nurse Practitioner (NP) V21 stated that both Resident R2 and Resident R4 are completely dependent on staff for all care and are severely cognitively impaired. V21 NP stated that the facility should, at minimum:Turn, reposition, and provide incontinence care at least every two hours.Provide proper nutrition.Complete thorough admission assessments.Conduct weekly skin assessments, as required by facility protocol.V21 NP stated that the facility did cau

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Goldwater Care Danville

620 Warrington Avenue Danville, IL 61832

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Based on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants (CNAs). This failure affects all 83 residents in the facility. Findings include:On 10/1/25 between 10:30AM and 11:04AM there were a total of 7 CNAs working in the facility; 3 on the East wing, 2 on the Middle wing, and 2 on the [NAME] wing.The facility's Resident Council Meeting Minutes dated 6/30/25, 7/29/25, 8/26/25, and 9/29/25 document concerns regarding call light response times, water not being passed in the evenings, and showers not being given on scheduled shower days. The facility's Facility Assessment Tool dated 2/26/25 documents the facility has 90 licensed beds but does not identify their average daily census. This assessment documents the facility has an average of 10-15 residents with stage three or stage four pressure ulcers. This assessment documents the facility's staffing plan includes eight CNAs on dayshift and six CNAs on nights. The facility's Daily Staffing Sheets dated 9/14/25-10/1/25 document 16 day shifts had less than 8 CNAs and 11 night shifts had less than 6 CNAs. On 10/1/25 between 10:37 AM and 10:57 AM the following staff were interviewed: V38 CNA confirmed there were 7 CNAs currently working in the facility, 3 CNAs on East, 2 on Middle, and 2 on West. V14 Registered Nurse stated the facility needs 4 CNAs on East, 2 on Middle and 2 on West. V14 stated at times they have to pull

a CNA from the East wing to make 2 CNAs on each hall, and the resident rooms have to be divided up between the CNAs, which doesn't seem to be enough staff. V36 CNA stated there is suppose to be 4 CNAs

on East, 2 on Middle and 2 on West, but about 35% of the time we work with less than that with only 2 on each unit. V36 stated we have to help each other with the mechanical lifts and call light response is also affected. V37 CNA stated sometimes we work with 6 CNAs on day shift, which is considered short staffed,

we are suppose to have 8. V37 stated when that happens we are assigned to 15 residents, showers get missed, and it affects our ability to reposition residents every two hours. V37 stated V37 doesn't feel like one CNA for middle wing is enough for night shift, sometimes the heavy wetters are soaked in the morning when V37 reports to work. V28 CNA stated there are suppose to be 4 CNAs on East, 2 on Middle and 2 on West; sometimes that is not what we are staffed with due to call offs and two employees recently quitting.

V28 stated management tries to get people to come in when there are call offs and V28 often gets calls on her days off asking if she is able to come in to work. V28 stated when there are less than 8 CNAs on day shift, it is harder to get to call lights quickly and residents have to wait while we find help to assist with transferring them out of bed. V28 stated we try to stay on top of repositioning residents, but it depends on

the day and sometimes it is closer to 3 hours between repositioning. On 10/1/25 at 12:04 PM V2 Director of Nursing stated currently we staff 8 CNAs on day shift, 4 on East, 2 on Middle and 2 on West. V2 stated night shift is staffed with 6 CNAs, 2 on each unit. V2 stated we recently changed night shift staff to have four CNAs for 12 hours and two that work 6-10PM. V2 stated recently the CNAs said that wasn't working so now

we are doing five for 12 hour shifts. V2 stated the facility's average census is 70-80. V2 reviewed the 9/14/25-10/1/25 staffing sheets and confirmed they accurately reflect the CNA staffing, which does not match the staffing plan as outlined in the facility assessment. On 10/1/25 at 12:58 PM V2 provided a resident list report dated 10/1/25 with a total of 41 resident names highlighted residents. V2 confirmed the highlighted residents are those that require two person staff assist for transfers/cares. This list documents

the facility's census of 83 residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Goldwater Care Danville

620 Warrington Avenue Danville, IL 61832

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759

Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5%. A full medication administration observation was completed with three errors out of 28 opportunities resulting in a 10.7% medication error rate. This failure affects one (Resident R11) resident out of seven residents reviewed for medication administration in a sample list of 14 residents. Findings include:Resident R11's Physician Order Sheet (POS) dated September 2025 documents physician orders starting 4/15/25 with no end date to administer Sertraline 175 mg daily, 3/22/25 with no end date to administer Calcium 600 milligrams (mg) + Vitamin D3 20 micrograms (mcg) daily and 7/28/25 with no end date to administer 175 micrograms (mcg) Levothyroxine. This same POS also has a physician order to administer Levothyroxine 225 mcg from 9/11/25-9/18/25 and Levothyroxine 175 mcg from 9/19/25-9/29/25. Resident R11's Medication Administration Record (MAR), dated September 2025, documents that Resident R11 was administered Levothyroxine 225 mcg at 8:00 AM and another dose of Levothyroxine at 8:00 AM (totaling 450 mcg) from 9/11/25 to 9/18/25. The same MAR shows that Resident R11 was administered Levothyroxine 175 mcg at 6:00 AM and another 175 mcg at 8:00 AM (totaling 400 mcg) from 9/19/25 to 9/21/25.Resident R11's Laboratory (Lab) Results Report, dated 9/11/25, documents Resident R11's Thyroid Stimulating Hormone (TSH) level as abnormal, with a result of 0.26 micro-international units per milliliter (uIU/mL). The report states the normal range for TSH is 0.34-4.82 uIU/mL.Resident R11's Nurse Progress Notes, dated 9/21/25 at 4:46 PM, document that Resident R11 had two Levothyroxine (Synthroid) orders: 175 mcg and 225 mcg. The same note confirms the facility consulted V19, the Medical Director, who issued a new order to discontinue the 225 mcg Levothyroxine and continue Resident R11's 175 mcg daily dose.On 9/21/25 at 8:55 AM, V10, Registered Nurse (RN), administered Resident R11's scheduled medications. V10 administered Resident R11's Sertraline 150 mg, Levothyroxine 225 mcg, and Calcium 600 mg + Vitamin D3 50 mcg.On 9/21/25 at 11:00 AM, V10, Registered Nurse (RN), confirmed she had administered incorrect doses of Sertraline, Levothyroxine, and Calcium + Vitamin D3 to Resident R11. V10 stated

she thought she had everything but made a few errors. V10 also stated she would be more careful in the future.On 9/22/25 at 3:00 PM, V2, Director of Nurses (DON), stated that residents are expected to receive all of their prescribed medications as ordered. V2 further stated that any medication not administered-whether due to error or omission-must be reported to the physician and the resident's family.The undated facility policy titled Medication Administration General Guidelines documents the five rights-right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: 1. When the medication is selected, 2. When the dose is removed from the container and finally 3. Just after the dose is prepared and the medication is put away.

Check #1 select the medication-label, container and contents are checked for integrity and compared against the medication administration record (MAR) by reviewing the five rights. Check #2 Prepare the dose-the dose is removed from the container and verified against the label and the MAR by reviewing the five rights. Check #3 Complete the preparation of the dose and re-verify the label against the MAR by reviewed the five rights. Medications are administered in accordance with written orders of the prescriber.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Goldwater Care Danville

620 Warrington Avenue Danville, IL 61832

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to maintain Contact Isolation Precautions for one (Resident R4) resident out of four residents reviewed for Infection Control in a sample list of 14 residents.Findings include:Resident R4's Electronic Medical Record (EMR) documents the following medical diagnoses: fusion of the spine (lumbar region), spondylolisthesis, Parkinson's disease without dyskinesia, hypokalemia, anemia, vascular dementia, Escherichia coli, methicillin-susceptible Staphylococcus aureus infection, disorders of muscle, dysphagia (oropharyngeal phase), difficulty in walking, abnormal posture, reduced mobility, and pressure ulcers on the right buttock, left hip, sacrum, and left ankle.Resident R4's Minimum Data Set (MDS), dated [DATE REDACTED], documents Resident R4 as severely cognitively impaired. The same MDS notes that Resident R4 is completely dependent on staff for assistance with eating, oral hygiene, toileting, dressing, personal hygiene, and bed mobility.Resident R4's Physician Order Sheet (POS), dated September 2025, includes a physician order starting on 9/18/25 to place Resident R4 on contact isolation precautions due to a wound infection.On 9/20/25 at 2:45 PM, a sign reading Contact Isolation was posted on Resident R4's room door. Personal protective equipment (PPE) supplies-including masks, gowns, and gloves-were hanging on the door.On 9/20/25 at 2:50 PM, V9 (Licensed Practical Nurse, LPN) and V10 (Registered Nurse, RN) completed pressure ulcer care for Resident R4's sacrum, right ischium, right buttock, left inner buttock, and right hip. Prior to entering Resident R4's room, V9 stated

she was entering without PPE to sanitize the bedside table. She entered the room without donning a gown or gloves and used her bare hands to turn the bedside table around twice to clean the top surface. V9 then exited the room without washing her hands or performing hand hygiene and arranged Resident R4's dressing supplies on top of the treatment cart outside the door.On 9/21/25 at 1:15 PM, V2 (Director of Nurses, DON) stated that staff must ensure contact isolation precautions are maintained. V2 confirmed that staff should wear appropriate PPE-specifically a gown and gloves-when entering the room of any resident on contact isolation. V2 also confirmed that V9 contaminated the wound supplies, which were later used on Resident R4's multiple infected pressure ulcers.The facility policy titled Infection Precaution Guidelines, revised May 15, 2023, states that contact precautions are to be used for residents known or suspected to be infected with microorganisms that can be easily transmitted through direct or indirect contact, such as handling environmental surfaces or resident care items.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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