Goldwater Care Danville

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Apr 4, 2025

  3.) During intermittent observations on 3/31/25 and 4/1/25 between 9:30 AM and 4:00 PM there was no Enhanced Barrier Precautions (EBP) sign posted on R38's room door and there was no cart containing personal protection near R38's room door. On 4/01/25 at 1:11 PM V48 Certified Nursing Assistant entered R38's room and removed R38's socks in order to observe R38's heel wound dressings. V48 was not wearing a gown. On 4/01/25 at 3:38 PM V8 Assistant Director of Nursing transferred R38 into bed and administered R38's sacral and heel pressure ulcer treatments without wearing a gown. V8 confirmed R38 is not on EBP. V8 stated V8 thought EBP was only needed for open wounds and indwelling devices. V8 confirmed stage two pressure ulcers are considered open wounds. […]

• Immediate jeopardy, widespreadF695Nov 27, 2024

  Based on interview and record review the facility failed to provide timely emergency airway management and suctioning for a resident in respiratory distress during a medical emergency. This failure affected one of three residents (R1) reviewed for emergency airway management and has the potential to affect all 77 residents residing in the facility. This failure resulted in R1's subsequent death. The Immediate Jeopardy began on [DATE] when R1 aspirated and could not maintain adequate oxygenation. Staff could not locate the suctioning equipment, made multiple trips in and out of R1's room getting missing equipment, and could not get the suctioning equipment functioning therefore delaying emergency airway management and respiratory treatment for R1. […]

• Immediate jeopardy, isolatedF686Oct 2, 2025

  A partial extended survey was conducted. Failures at this level require two separate deficient practice statements. A. Based on observation, interview and record review the facility failed to reposition a resident timely, prevent cross contamination during wound care, provide the correct wound treatment, complete skin assessments timely, update a resident's care plan with pressure sore interventions, provide wound supplements, obtain ordered laboratory tests timely, and implement care plan interventions for pressure sore care and prevention for one (R4) resident of five residents reviewed for pressure sores. These failures resulted in R4 obtaining 18 separate facility acquired Pressure Sores from January 2025 through September 2025. […]

• Immediate jeopardy, isolatedF600Jun 13, 2024

  Based on observation, interview, and record review the facility failed to protect the resident's right (R1) to be free from sexual abuse by another resident (R2) by failing to supervise R2, a resident with a known history of behaviors of inappropriate touching towards other residents (R3, R4, R5, R6, R7, R8, R10, R14). R1-R8, R10, and R14 are nine of 14 residents reviewed for abuse in the sample list of 16. These failures resulted in R2 sexually abusing R1 when R2 was left unsupervised. The Immediate Jeopardy began on 5/24/24 when R1 was sexually abused by R2. V1 Administrator was notified of the Immediate Jeopardy on 6/11/24 at 11:21 AM. […]

• Actual harm, isolatedF689Jul 20, 2026

  Based on interview and record review, the facility failed to ensure staff used two-person assistance during mechanical lift transfer and failed to inspect mechanical lift slings prior to each use in accordance with facility policy and manufacturer recommendations for one (R1) of three residents reviewed for accidents on a sample list of eight. These failures resulted in R1 falling from a mechanical lift while suspended in the air and sustaining a comminuted, displaced and impacted proximal left humeral fracture (shoulder), and a small subgaleal hematoma (pocket of blood between skull bone and scalp skin). This past non-compliance occurred from 7/1/26 to 7/2/26.Findings include:The facility's policy, Manual Gait Belt and Mechanical Lifts, revised 1/19/18, includes 'Guidelines: 4. […]