Goldwater Care Danville

Nurse who was down the east hall passing medication. V3 stated that V3 asked to conduct a narcotic count with V6 and V6 told V3 that V3 is busy. V3 stated that V3 got off of work at 6:30 PM and returned to work on 8/30/25 at 6:00 AM for V3's next shift. V3 stated that V3 conducted a narcotic count with V5 who's shift was ending. V3 stated that V3 asked V5 if R1's is the other bottle of Ativan was in the refrigerator and V5 became defensive and said, what don't do that to me. V3 stated that V5 said there was never another bottle of Ativan in the refrigerator and only one controlled substance form in the narcotic book. V3 stated there was not a second controlled substance form in the narcotic book, like there was yesterday morning, and there was no bottle of Ativan in the refrigerator in the locked medication room. On 11/25/25 at 2:00 PM V2 Director of Nursing Stated that on 9/1/25 V3 Registered Nurse notified V2 of a missing 30 milliliter bottle of Ativan. V2 stated that V3 informed V2 that V3 had worked on 8/29/25 from 6:00 AM to 6:30 PM and when V3 came onto work that morning V3 conducted a narcotic count with the nurse whose shift was ending. V2 stated that V3 informed V2 R1 had a bottle of Ativan open in the medication cart, and an unopened bottle in the refrigerator in the locked medication room. V2 stated that V3 informed V2 that there were 2 sheets in the narcotic book, 1 for the opened and 1 for the unopened bottle. V2 stated that V3 informed V2 that V3 passed morning medications on the East Hall and when finished gave keys to V6 Agency Registered Nurse who told V3 that V6 was busy and didn't perform a narcotic count. V2 stated that V3 further informed V2 that when V3 returned to work on 8/31/25 at 6:00 AM and conducted a narcotic count with V5 Licensed Practical Nurse that the bottle of Ativan that was in the refrigerator was gone and also the controlled substance form for the second bottle was gone.

Prior to the survey date of 11/26/25, the facility took the following actions to correct the non-compliance:On 9/1/25, R1's Ativan 30 milliliter bottle was replaced by the facility.On 9/1/25, the Quality Assurance Committee developed a Plan of Correction for the 8/30/25 incident and a Performance Improvement Plan.On 9/1/25, the Director of Nursing and Administrator provided in-service education to nursing staff on Controlled Substance Policy/Count and Narcotic Destruction Policy.On 9/1/25, the facility standardized communication pathways with pharmacy on dropping off and picking up controlled medications.Starting on 9/1/25, the Director of Nursing and/or designee began auditing medication carts/medication rooms daily x 7 days a week x 6 weeks to ensure controlled substances (pills, patches and liquids) matched count sheetThe facility QAPI Committee will continue to monitor performance to ensure corrective actions related to the 9/1/25 incident are effective.Completion date of substantial compliance: 11/24/25.

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