Donalson Care Center

In the surveyor’s words

From the most serious findings on record at Donalson Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 3, 2021

  Based on facility policy review, medical record review, review of facility investigation, and interviews, the facility failed to ensure a resident was safely and correctly transferred, causing a fall with a transverse fracture of the distal fibular metaphysis and bilateral non-displaced tibial fractures (age indeterminate), resulting in harm to Resident #1. The harm affected 1 of 3 residents (Resident #1) reviewed for falls. Findings include: Review of the facility policy titled, Fall Prevention Program, dated 2/5/2021, revealed .Patients will be cared for in a safe environment. […]

• No harm, potential for more than minimal, patternF921Jun 30, 2021

  Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain a sanitary environment for 3 of 5 sample residents (Resident #23, #28, and #48) who required enteral tube feeding. The findings include: Review of the facility's policy, titled, Daily Occupied Patient Room Cleaning, dated 12/9/2020, revealed, .Disinfect and spot clean: Using a Hospital Approved Disinfectant and a clean cloth, clean all spots and hand contact areas working clockwise around the room. […]

• No harm, potential for more than minimal, isolatedF689Aug 18, 2026

  Based on facility policy review, medical record review, facility investigation review, and interview, the facility staff failed to timely notify the responsible nursing staff of a fall for 1 resident, (Resident #9) of 3 residents reviewed for falls. The facility was cited at F 689 at a Scope and Severity of D as Past Non-Compliance. No additional corrective actions are required. The facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Fall Prevention-Program Policy, dated 7/2026, revealed . […]

• No harm, potential for more than minimal, isolatedF550Mar 12, 2025

  Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure medical information was not visible for 2 residents (Resident #34 and Resident #57) of 83 residents observed for dignity. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 1/2025, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Maintain resident privacy . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, and Adult Failure to Thrive. […]

• No harm, potential for more than minimal, isolatedF609Mar 12, 2025

  Based on facility policy review, medical record review, facility documentation review, and interview the facility failed report an allegation of injury of unknown origin timely for 1 resident (Resident #20) of 5 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, revised 8/12/2024, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of property are investigated, and reported immediately to the Facility Administrator, the… […]