Danville Post-Acute Rehab

In the surveyor’s words

From the most serious findings on record at Danville Post-Acute Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Oct 11, 2024

  Based on observation, interview, and record review, the facility failed to accurately assess two of 14 sampled residents (Resident 18 and Resident 7) in the quarterly Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessments. 1. Resident 18's quarterly MDS assessment was inaccurately coded Yes for diagnosis of pneumonia (an infection of one or both lungs caused by bacteria, viruses or fungi causing difficulty in breathing, cough, fever, and chills) when Resident 18 did not have active pneumonia. 2. […]

• No harm, potential for more than minimal, patternF677Oct 11, 2024

  Based on observation, interview, and record review, the facility failed to provide nail care and hygiene to one of two sampled residents (Resident 11). Resident 11 had long toenails on both feet. This failure placed Resident 11 at risk for poor hygiene, pain/discomfort from long nails, scratching themselves and infections. Findings: During a review of Resident 11's Admission Record, the record indicated Resident 11 was admitted to the facility in December 2022. During a review of Resident 11's Minimum Data Set (MDS is a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 6/28/24, the assessment indicated Resident 11 was able to understand others and was able to make herself understood. […]

• No harm, potential for more than minimal, patternF755Oct 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure the appropriate use of lidocaine patches (to treat pain) and the accountability of controlled medications (those with high potential for abuse and addiction) when: 1. The nursing staff failed to remove lidocaine patches after 12 hours as ordered by the prescriber and per manufacturer recommendations for two out of eight residents (Residents 27 and 194). This failure had the potential for residents to receive an excessive dose of lidocaine which could result in side effects, including swelling and skin irritation; and 2. […]

• No harm, potential for more than minimal, patternF758Oct 11, 2024

  Based on observation, interview, and record review, the facility failed to accurately monitor, document, and intervene for potential side effects of haloperidol (an antipsychotic medication, used to treat symptoms of psychosis, such as perception of something that is not real and suspiciousness, etc.) for one of five sampled residents (Resident 11) when Resident 11 exhibited abnormal, consistent, involuntary lateral movements of the jaw while talking. This failure resulted in inaccurate reflection of Resident 11's clinical status and placed her at risk for experiencing further increased side effects of haloperidol. […]

• No harm, potential for more than minimal, patternF759Oct 11, 2024

  Based on observation, interview, and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during medication administration for two out of eight residents (Residents 27 and 33). This failure resulted in medications not given according to the physician's orders and had the potential for residents to not receive the full therapeutic effects of medications. Findings: 1. During a medication pass observation on 10/07/24 at 9:38 a.m., licensed vocational nurse (LVN) 4 was observed preparing and administering seven medications to Resident 27. LVN 4 was observed pulling a bubble pack of Eliquis (brand name for apixaban, a blood thinner) 2.5 mg labeled for Resident 194 and preparing for Resident 27. […]