Nortonville Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689Jan 14, 2026

  The facility had a census of 34, with 14 residents in the sample, and one resident reviewed for substance use disorder. Based on observation, interview, and record review the facility failed to prevent, identify, and intervene in Resident (R) 11's substance use disorder, which placed residents in immediate danger of serious harm or death. R11' Electronic Health Record revealed a history of substance use disorder, charting to indicate signs and symptoms of active substance use, and two instances of the resident having drug paraphernalia in his room. On [DATE] at 02:14 PM facility staff saw a green tackle box and a red basket on the floor in R11's room which contained pill bottles, lighters, books, and other items scattered next to it. […]

• Immediate jeopardy, widespreadF755Jan 14, 2026

  The facility reported a census of 34 residents. Based on observation, interview, and record review the facility lacked a system for records of receipt through disposition of all controlled medications, in sufficient detail to enable accurate reconciliation and ensure drug records were in order. The facility also failed to ensure a record system to account for all controlled medication which was maintained and periodically reconciled. The facility pharmacy lacked onsite presence in the facility to assist in the destruction of controlled narcotic substances from February 2025 until [DATE]. The facility had a locked cabinet inside the medication room used for narcotic medications awaiting destruction. […]

• Immediate jeopardy, widespreadF880Jan 14, 2026

  The facility had a census of 34 residents with 14 in the sample. Based on observation, interview, and record review the facility failed to implement and maintain an effective infection prevention and control program in accordance with a facility assessment, regulatory requirements, and professional standards of practice. Upon entrance to the facility resident rooms had clothing piled on side tables and on the floors, trash cans in resident rooms were full, and staff present failed to maintain infection control practices when transporting laundry, trash, and multi-resident use medical equipment. […]

• Immediate jeopardy, isolatedF600Nov 19, 2025

  The facility identified a census of 38 residents. The sample included three residents for abuse. Based on record review, observations, and interviews, the facility failed to prevent an incident of resident-to-resident abuse and protect one resident, Resident (R) 2, from abuse. On 11/19/25 at 01:53 PM R1, a cognitively impaired resident with known aggressive behavior, entered the dining area and, without provocation, forcefully punched (with a closed fist) R2. There were approximately seven to eight additional residents in the dining area at the time of the altercation. R1 punched R2 two to three times in the left shoulder while R2 and others began shouting. R2 tried to block R1's punches, and both residents fell from their wheelchairs to the floor. […]

• Immediate jeopardy, isolatedF684Aug 26, 2024

  The facility identified a census of 23 residents. The sample included nine residents. Based on record review and interviews, the facility failed to immediately respond to a change in health status and failed to obtain physician involvement when Resident (R) 1 had a critical lab result and subsequently developed abnormal blood pressure, lower than the physician ordered parameter. The facility further failed to immediately act upon the resident and/or his representative's request to seek acute care for treatment of his declining health situation. On 08/13/24, R1 fell from a full body lift during transfer. On 08/14/24, R1 complained of intermittent back pain and shakiness. […]