Danville Centre for Health & Rehabilitation

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents were allowed to return to the facility for 1 of 5 sampled residents (Resident (R)1).

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for 1 of 6 sampled residents, Resident (R) 1. The facility failed to administer R1's scheduled monthly invega sustenna injection (an antipsychotic medication used to treat schizophrenia) on 04/19/2026. Additionally, the facility failed to notify the resident's physician or guardian at the time of the missed medication. R1 had increased behaviors in April and May 2026, which resulted in multiple transfers to the local hospital, and an admission to the state psychiatric facility from 05/08/2026 until 05/21/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide routine drugs to its residents as ordered or obtain them for one (1) of six (6) sampled residents, Resident (R) 1. The facility failed to administer R1's scheduled monthly invega sustenna injection (an antipsychotic medication used to treat schizophrenia) on 04/19/2026 and did not promptly notify the pharmacy that the medication was unavailable. R1 did not receive his scheduled invega sustenna injection until 05/06/2026, 17 days later, resulting in increased behaviors in April and May 2026. R1 was admitted to the state psychiatric facility from 05/08/2026 until 05/21/2026. Additionally, on 05/31/2026, R1 was admitted to the local hospital's behavioral unit related to psychotic behaviors and psychosis and remained there during the Survey.

Inspectors wroteThe facility failed to ensure staff followed infection prevention and control practices during wound care for 2 of 3 residents (Resident 8 and Resident 6) of 22 sampled residents reviewed for wound care. Based on observation, interview, record review, and review of facility policy, the facility failed to implement its infection prevention and control program by not ensuring licensed nurses performed required hand hygiene and glove changes during wound care. This deficient practice placed 2 of 21 sampled residents (Residents R6 and R8) at risk for cross-contamination, wound deterioration, and increased infection.

Inspectors wroteBased on observation, interviews, and a review of facility policies, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.

Inspectors wroteBased on interview, record review, and facility document and policy review, it was determined the facility failed to ensure the comprehensive care plan for one (Resident (R) 2) of 14 sampled residents was implemented. R2 was assessed upon admission to be at risk for elopement and was care planned with the goal of not leaving the facility without staff supervision. On [DATE], R2 eloped from the facility without staff knowledge when the resident's care planned wander guard (door alarm system used to alert staff of resident's attempts to leave the facility) was not functioning and staff failed to provide additional monitoring, supervision, and/or interventions to prevent the resident from exiting the facility. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, it was determined the facility failed to provide adequate monitoring and supervision to prevent elopements for one (Resident (R) 2) of four sampled residents reviewed for elopement risk out of a total sample of 14 residents. On [DATE], R2 exited the facility without staff knowledge during a time period in which the facility's wander guard system (door alarm system used to alert staff of a resident's attempts to leave the facility) was not functioning. The facility's failure to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopements caused or is likely to cause serious injury, harm, impairment, or death to a resident.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure four (4) of thirty-five (35) sampled residents (Resident #10, Resident #67, Resident #174, and Resident #175), who were all cognitively impaired and lacked the capacity to consent to sexual relations, were protected from sexual abuse. In addition, it was determined the facility failed to protect two (2) of six (6) sampled residents (Resident #37 and Resident #174) from physical abuse. 1. Review of the facility's investigation documentation revealed on 12/06/2021, Resident #174 and Resident #10 were found by staff in Resident #10's room. Both residents were observed to have their pants down to mid-thigh, and Resident #10 had his/her hand on Resident #174's thigh. Resident #10 was placed on one (1) to one (1) supervision; [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented for two (2) of thirty-five sampled residents, Resident #67 and #175. Interview with Kentucky Medication Aide (KMA) #3 revealed that on 01/15/2022, Housekeeper #2 came to her and reported that she needed to come to the room of Resident #175. KMA #3 stated when she entered the room, Resident #67 and Resident #175 were engaged in sexual intercourse. Housekeeper #2 failed to stay with the residents to protect the residents from abuse and therefore failed to implement the abuse policy. The facility's failure to ensure that established policies and procedures were followed when allegations of abuse occurred has caused or is likely to cause serious injury, harm, impairment, or death to a resident. [...]

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to thoroughly investigate three (3) allegations of sexual abuse involving four (4) of thirty (35) sampled residents (Resident #10, Resident #74, Resident #174 and Resident #175) to ensure appropriate action was taken to protect residents and prevent further sexual abuse/potential sexual abuse. Review of the facility's investigation, dated 12/06/2021, revealed Resident #174 and Resident #10 were found in Resident #10's room. Resident #10's pants were down to mid-thigh, as well as, Resident #174's pants down to mid-thigh. Resident #10 had his/her hand on Resident #174's thigh. [...]

Inspectors wroteBased on interview, record review, and review of facility policy it was determined the facility failed to review and revise the person-centered comprehensive care plan for four (4) of thirty-five (35) sampled residents (Resident #10, Resident #37, Resident #67, Resident #174 and Resident #175). Record review and interview revealed Resident #37, Resident #67, Resident #174, and Resident #175 had displayed behaviors that put them at risk for abuse and had care plans in place for behavioral problems. Review of the facility's investigation revealed, on 12/06/2021, Resident #174 and Resident #10 were found in Resident #10's room with Resident #10's pants down to mid-thigh. Resident #174's pants were down to mid-thigh and Resident #10 had his/her hand on Resident #174's thigh. [...]

Inspectors wroteBased on interview, record review, review of the Administrator's Job Description, and review of the facility's policies and procedures, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being and protect its residents from abuse/potential abuse. The facility's Administration failed to ensure residents were free from abuse; failed to ensure its abuse policies were implemented; failed to ensure thorough investigations of abuse allegation incidents were conducted; and, failed to implement residents' Comprehensive Care Plans (CPs) for four (4) of four (4) allegations of resident abuse. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the Physician when a change occurred in a resident, and there was a need to alter the resident's treatment for one of thirty-five (35) sampled residents (Resident #18). Resident #18 had orders to notify the physician when the resident's blood glucose level was greater than 400 milligrams per deciliter (mg/dl). However, the facility failed to notify the resident's physician on 11/17/2021, 12/18/2021, 01/01/2022, 01/04/2022, and on 02/08/2022, when Resident #18's blood glucose level was elevated above 400 mg/dl.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of thirty-five (35) sampled residents (Resident #18). The facility had developed a plan of care for Resident #18 related to Diabetes Mellitus. Interventions to be followed by staff included notifying the resident's physician when his/her blood glucose level was above 401 milligrams per deciliter (mg/dl). However, on five (5) occasions from 11/17/2021 through 02/08/2022, the resident's blood glucose was above 401 mg/dl, but staff failed to follow the resident's plan of care and did not notify the resident's physician.

Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to ensure residents received care and treatment in accordance with accepted standards of practice to treat and prevent adverse events related to Hyperglycemia (high blood sugar) for one (1) of thirty-five (35) sampled residents (Resident #18). Resident #18's Blood glucose levels were elevated above 400 mg/dl (normal range below 125) on 11/17/2021, 12/18/2021, 01/04/2022 and on 02/08/2022. However, there was no evidence found to indicate that the resident's condition was monitored after the levels were obtained, that staff rechecked the resident's glucose levels, or called the resident's physician to obtain further orders for evaluation and treatment of the resident's condition.

Inspectors wroteBased on observation, interview and review of facility Policy, it was determined the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety. Observation of the Kitchen during initial tour on 04/09/19, revealed the PM April 2019 cleaning schedule was not initialed to indicate the Cook, Dessert Aide and the Drink Aide had performed cleaning duties. In addition, the cook was observed to use the incorrect sanitizer test strips to test the sanitizer for the pot and pan sink. Also, the fryer oil appeared dark black to brown in color with food particles floating on the surface. Further, there were five (5) sheet pans on an open rack in the kitchen which had cereal crumbs on top; and the open rack had pans which were stored on the lowest shelf, less than six (6) inches from the floor. [...]

Inspectors wroteBased on observation, interview, and review of the facility's Policies and procedures, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation on 04/09/19 of the Medication Storage room for the Recovery Hall, revealed the room was unorganized and cluttered with supplies and boxes of liquid supplement and tube feeding haphazardly stored and totes of discontinued medications sitting directly on the floor. Also the Recovery Medication Cart #1, had sticky liquid medication bottles with medication running down the sides of each bottle, and the labels and bottles were discolored. The cart also contained one (1) Ventolin HFA Inhaler, ninety (90) micrograms (mcg) which had been removed from the foil overwrap and had no open date; one (1) Symbicort Inhaler, 164.5 mcg which was in use with no open date; [...]

Inspectors wroteBased on observation, interview, and review of facility Policy, it was determined the facility failed to follow standard precautions to prevent the spread of infection for one (1) of twenty-one (21) sampled residents (Resident #13). Observation of the lunch meal service, on 04/09/19, revealed a State Registered Nurse Assistant (SRNA) handled Resident #13's sandwich with her bare hands.

Inspectors wroteBased on observation, interview, and review of the facility's Policy, it was determined the facility failed to post the following information: facility name, current date, the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, on a daily basis at the beginning of each shift, in a clear and readable format, and in a prominent place readily accessible to residents and visitors. Observations 04/09/19 through 04/11/19, revealed facility Nurse Staffing information was not posted in a prominent place readily accessible to residents and visitors.