Health inspection·November 26, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the security and proper accounting of a controlled substance (Ativan) for R1. This failure affected one of three residents (R1) reviewed for abuse in the sample of three. This past non-compliance occurred from 8/30/25 to 11/24/25.Findings Include:R1's Facility census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Hospice, Hemiplegia and Hemiparesis, Type 2 Diabetes, COPD, Chronic Respiratory Failure with Hypoxia, Cerebrovascular Disease, Major Depressive Disorder, Obstructive and Reflux Uropathy, Retention of Urine, Obesity, Presence of Urogenital Implants, Delusional Disorders, Presence of Cardiac Pacemaker, Mood [Affective] Disorder, Vascular Dementia, HTN, GERD, Heart Disease, Chronic Kidney Disease Stage 3 and Anxiety Disorder. R1 Minimum Data Set (MDS) dated [DATE] documents R1 Brief Interview for Mental Status (BIMS) score 10, moderate cognitive impairment and received antianxiety medications the last 7 days.R1's Physician Order Sheet dated 8/6/25 documents Lorazepam Oral Concentrate 2 milligram/milliliter, give 0.25 milliliters by mouth every 3 hours as needed for restlessness or anxiety.R1's Physician Order Sheet dated 8/6/25 documents Lorazepam Oral Concentrate 2 milligram/milliliter, give 0.25 milliliters by mouth every 3 hours as needed for restlessness or anxiety.Pharmacy Deliver Form dated 8/8/25 documents manifest ID# 5449229/001-R1-Lorazepam concentrate 2 milligram/milliliter x 30 doses. Delivered.Pharmacy Deliver Form dated 8/19/25 documents manifest ID# 5456952/001-R1-Lorazepam concentrate 2 milligram/milliliter x 30 doses. Delivered.V5 Licensed Practical Nurse Witness Statement dated 9/4/25 documents on 8/30/25 that V5 conducted a narcotic medication count on the 2 East medication cart with V3 Registered Nurse the oncoming nurse V3 asked V5 about the other Ativan in the refrigerator and V5 told V3 there was never anything in the refrigerator. There was nothing to count and only one controlled substance form for R1's Ativan that in in the medication cart.The Facilities Narcotic/ Controlled Substances-Counting Policy 11/26/27 documents: Purpose: 1. To count controlled substances with a partner and to verify the accuracy of the log. 2. Knowledge of correct response should an error be discovered in the controlled substance count. General Guidelines: Always participate in the counting of the controlled substances at the beginning and ending of your shift. Never say, go ahead without me and I'll sign later. Never leave it at someone else's discretion when you are the one on duty. If you do not observe the medications that you sign as being present, you may be implicated if the medications are missing later. On 11/25/25 at 11:42 AM V3 Registered Nurse stated that on 8/29/25 V3 worked the 6:00 AM - 6:30 PM shift. V3 stated when coming on V3 conducted a narcotic count with the nurse whose shift was ending and that R1 had one bottle (30 milliliters) of Ativan in the medication cart and one bottle in the refrigerator. V3 stated that there were 2 controlled substance forms in the narcotic book for R1's Ativan, one was started and the other blank for the bottle in the refrigerator. V3 stated that V3 passed the morning medications on the 2 East Hall, and was an extra nurse and had other duties, and gave the keys the medication cart to V6 Agency Registered Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145183 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Danville 620 Warrington Avenue Danville, IL 61832 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)