Inspection Reports for
Danville Centre for Health and Rehabilitation
642 NORTH THIRD STREET, DANVILLE, KY, 40422
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
77% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Oct 27, 2025
Visit Reason
An Abbreviated Survey investigating complaint 2651084 was initiated and concluded on 10/27/2025.
Complaint Details
Complaint 2651084 was investigated and found to be in compliance with no deficiencies identified.
Findings
Complaint 2651084 was in compliance with regulatory requirements, and no deficient practice was identified.
Inspection Report
Routine
Deficiencies: 2
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control practices and to evaluate the safety, cleanliness, and comfort of the nursing home environment.
Findings
The facility failed to ensure staff followed infection prevention and control practices during wound care, risking cross-contamination and infection for residents. Additionally, the facility environment was found to be unsafe and unsanitary, with peeling paint, rust, mold-like substances in air units, and general disrepair affecting resident comfort and safety.
Deficiencies (2)
F 0880: The facility failed to ensure licensed nurses performed required hand hygiene and glove changes during wound care for 2 of 3 residents reviewed, risking cross-contamination and infection.
F 0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment, with peeling paint, rust, mold-like substance in air units, and unaddressed maintenance issues.
Report Facts
Residents reviewed for wound care: 22
Residents affected by infection control deficiency: 2
Residents affected by environmental deficiency: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | LPN | Observed failing to change gloves and wash hands during wound care for Resident R8 |
| Licensed Practical Nurse 3 | LPN | Observed failing to change gloves and wash hands during wound care for Resident R6 |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control expectations and environmental concerns |
| Administrator | Administrator | Interviewed regarding staff expectations and prioritization of maintenance tasks |
| Licensed Practical Nurse 6 | LPN | Interviewed about environmental concerns and facility conditions |
| Environmental Services Manager | Environmental Services Manager | Interviewed about maintenance priorities and facility conditions |
| Maintenance Director | Maintenance Director | Interviewed about maintenance system and prioritization of repairs |
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 2
Date: Jan 24, 2025
Visit Reason
An Abbreviated Survey investigating multiple complaints was conducted from 01/09/2025 through 01/24/2025 to assess compliance with 42 CFR 483 subpart B, including an Immediate Jeopardy (IJ) situation related to resident elopement.
Complaint Details
The survey was complaint-driven, investigating multiple complaints (KY00036555, KY00038311, KY00038737, KY00039303, KY00040056, KY00041843, KY00041872, KY00042943, KY00043550, KY00043936, KY00044616). Immediate Jeopardy was identified related to failure to prevent elopement but was removed after corrective actions.
Findings
The facility failed to implement a comprehensive care plan and provide adequate supervision to prevent elopement of Resident 2, who eloped on 04/04/2023 during a period when the wander guard alarm system was not functioning due to sprinkler system testing. Immediate Jeopardy was identified but later removed. The facility implemented corrective actions including enhanced monitoring, staff education, door security improvements, and ongoing audits.
Deficiencies (2)
Failure to develop and implement a comprehensive care plan ensuring adequate supervision to prevent elopement of Resident 2.
Failure to provide adequate monitoring and supervision to prevent elopements, resulting in Resident 2 exiting the facility without staff knowledge.
Report Facts
Survey Dates: 2025-01-09 to 2025-01-24
Sample Size: 14
Residents at risk for elopement: 16
BIMS score: 3
Distance traveled during elopement: 120
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KMA7 | Kentucky Medication Aide | Responsible for Resident 2's supervision during elopement incident; reported being alone with 18 residents and unaware of elopement |
| RN1 | Registered Nurse | Reported that two staff were supposed to monitor hallways during alarm shutdown and that elopement could have been prevented with closer monitoring |
| Plant Operations Director | Plant Operations Director | Reported that staff were unaware that door alarms were silenced during sprinkler testing and no monitoring was in place |
| Social Services Director | Social Services Director | Reviewed and updated care plans and elopement profiles after incident |
| Vice President of Operations | Vice President of Operations | Completed root cause analysis and educated leadership on procedures after incident |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and involved in corrective action plan |
| Director of Nursing | Director of Nursing | Assessed Resident 2 after elopement, involved in corrective action plan and education |
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 2
Date: Jan 24, 2025
Visit Reason
The inspection was conducted as part of an annual survey and included investigation of an elopement incident involving Resident 2 (R2) during a sprinkler system inspection that disabled the wander guard alarm system.
Findings
The facility failed to implement a comprehensive care plan and adequate supervision to prevent elopement of a resident at risk (R2), resulting in Immediate Jeopardy. The wander guard alarm system was nonfunctional during sprinkler testing, and staff failed to monitor exit doors, allowing R2 to leave the locked unit unnoticed and fall outside. The facility subsequently implemented corrective actions including enhanced monitoring, staff education, door security improvements, and ongoing audits.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan with measurable actions to meet the resident's needs, resulting in failure to prevent elopement of a resident at risk during a period when the wander guard alarm system was not functioning.
F 0689: The facility failed to provide adequate supervision and monitoring to prevent elopements for a resident at risk, allowing the resident to exit the facility unnoticed during an alarm system shutdown.
Report Facts
Resident census: 74
Residents at risk for elopement: 16
Distance traveled by resident during elopement: 120
BIMS score: 3
Number of residents in sample: 14
Number of residents reviewed for elopement risk: 4
Number of residents affected: 1
Number of residents at risk in elopement binder: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KMA7 | Kentucky Medication Aide | Reported being the only direct care staff on the locked unit during the elopement and unaware of the resident's exit |
| RN1 | Registered Nurse | Stated there were supposed to be two staff members monitoring hallways during alarm shutdown and that elopement could have been prevented with closer monitoring |
| POD | Plant Operations Director | Reported awareness of the door alarm system shutdown and lack of monitoring during sprinkler system testing |
| DON | Director of Nursing | Conducted injury assessment post-elopement and involved in corrective action plan |
| Administrator | Initiated Code Green and involved in corrective action plan | |
| CNA8 | Certified Nursing Assistant | Was on lunch break during elopement and did not provide coverage for KMA7 |
| RNC | Regional Nurse Consultant | Involved in plan of correction and noted lack of system to ensure adequate staff coverage during alarm shutdown |
Inspection Report
Enforcement
Deficiencies: 7
Date: Feb 24, 2022
Visit Reason
The inspection was conducted due to multiple allegations of abuse, neglect, and failure to follow care plans at the facility, including incidents of sexual abuse and failure to notify physicians of critical changes in resident conditions.
Complaint Details
The inspection was complaint and allegation driven, involving multiple incidents of alleged sexual abuse, failure to protect residents from wandering-related incidents, failure to notify physicians of critical changes, and failure to follow care plans. Immediate Jeopardy was identified on 02/12/2022 and removed on 02/19/2022.
Findings
The facility failed to notify physicians of elevated blood glucose levels for Resident #18, failed to protect residents from sexual abuse and wandering-related incidents involving multiple residents, failed to revise care plans after incidents, and failed to conduct thorough investigations of abuse allegations. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (7)
F0580: The facility failed to notify the physician when Resident #18's blood glucose level was above 400 mg/dl on multiple occasions.
F0600: The facility failed to protect residents from sexual and physical abuse involving Residents #10, #37, #67, #174, and #175, including failure to provide increased supervision and implement care plan interventions.
F0607: The facility failed to implement policies and procedures to prevent abuse, neglect, and exploitation, including failure to follow abuse policy during incidents involving Residents #67 and #175.
F0656: The facility failed to implement Resident #18's comprehensive care plan related to diabetes management, including failure to notify the physician of elevated blood glucose levels.
F0657: The facility failed to review and revise person-centered comprehensive care plans for Residents #10, #37, #67, #174, and #175 after incidents involving behavioral issues and abuse risk.
F0684: The facility failed to provide appropriate treatment and care for Resident #18 related to hyperglycemia, including failure to monitor and notify the physician of elevated blood glucose levels.
F0835: The facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to protect residents from abuse and ensure care plans were followed and investigations conducted.
Report Facts
Residents sampled: 35
Blood glucose readings above 400 mg/dl: 5
BIMS scores: 1
BIMS scores: 2
Supervision level: 1
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KMA #1 | Kentucky Medication Aide | Observed Resident #10 and Resident #174 in inappropriate contact on 12/06/2021. |
| LPN #10 | Licensed Practical Nurse | Received report of sexual intercourse between Residents #67 and #175 on 01/15/2022. |
| KMA #3 | Kentucky Medication Aide | Reported and witnessed sexual intercourse between Residents #67 and #175 on 01/15/2022. |
| LPN #8 | Licensed Practical Nurse | Failed to notify physician of Resident #18's elevated blood glucose on 11/17/2021. |
| Unit Manager | Reviewed care plans and investigations; acknowledged lack of interventions for Resident #174. | |
| Administrator | Unsubstantiated sexual abuse allegations; responsible for investigations and oversight. | |
| Director of Nursing | Expected staff to follow care plans and monitor residents; acknowledged monitoring limitations. |
Inspection Report
Routine
Deficiencies: 4
Date: Apr 11, 2019
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to nurse staffing postings, medication storage and labeling, food service safety, and infection prevention and control.
Findings
The facility failed to post nurse staffing information in a prominent and accessible location. Medication storage and labeling practices were deficient, including unlabeled opened medications and expired supplies. Food service safety practices were inadequate, including improper sanitizer testing, unclean equipment, and poor hand hygiene. Infection control lapses were observed during meal service with staff handling food without proper hand hygiene or gloves.
Deficiencies (4)
F 0732: Facility failed to post daily nurse staffing information in a clear, readable, and accessible location for residents and visitors.
F 0761: Facility failed to ensure proper storage and labeling of drugs and biologicals, including unlabeled opened medications and expired supplies.
F 0812: Facility failed to store, prepare, and distribute food in accordance with professional standards, including improper sanitizer testing, unclean fryer oil, and poor hand hygiene by staff.
F 0880: Facility failed to implement infection prevention and control program; staff handled ready-to-eat food without proper hand hygiene or gloves.
Report Facts
Open date expiration days for medications: 90
Open date expiration days for medications: 60
Open date expiration days for medications: 28
Open date expiration days for medications: 42
Open date expiration days for medications: 56
Open date expiration days for medications: 90
Open date expiration days for medications: 45
Survey dates: 3
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