Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 60
Deficiencies: 4
Jun 2, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on June 2 and 3, 2025, to assess compliance with state regulations for Woodland Terrace of Danville.
Findings
The facility was found deficient in several areas including failure to assess a resident for medication self-administration annually, failure to date medication bottles and eye drops when opened, lack of documentation for drug disposal for discharged residents, and failure to provide required tuberculosis testing documentation for some residents. Corrective actions and policy updates were planned to address these deficiencies.
Deficiencies (4)
| Description |
|---|
| Failed to ensure a resident was assessed for self-administering medications for 1 of 5 residents reviewed. |
| Failed to date bottles and eye drops when opened for medication carts and medication rooms. |
| Failed to provide documentation of drug disposal/disposition for 2 of 2 residents reviewed. |
| Failed to provide a first and second step PPD (tuberculosis testing) for 2 of 3 residents reviewed. |
Report Facts
Residential Census: 60
Survey Dates: 2
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Breann Higgins | Executive Director | Named in relation to findings and interview during the inspection |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
May 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456659 regarding food and nutritional services.
Findings
The facility failed to wear hairnets, cover trash cans, and date opened food products during a kitchen observation. Specific issues included staff not wearing proper hair coverings, uncovered trash cans, and several food items not being dated.
Complaint Details
Complaint IN00456659 was investigated and state deficiencies related to the allegations were cited at R273.
Deficiencies (1)
| Description |
|---|
| Failure to wear hairnets, cover trash cans, and date opened food products in the kitchen. |
Report Facts
Residential Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cole Stites | Regional Director of Operations | Signed the report. |
| Chef 2 | Observed not wearing proper hairnet and beard cover; interviewed regarding kitchen practices. | |
| Server 4 | Observed not wearing a hair net. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Aug 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439605 regarding allegations related to bruising of unknown origin and an incident involving law enforcement at Woodland Terrace of Danville.
Findings
The facility failed to report bruising of unknown origin and an incident with law enforcement to the Indiana Department of Health. Additionally, the facility failed to keep cognitively impaired residents separated as requested by family members. The residents involved were found safe and unharmed, but deficiencies were cited related to administration, management, and evaluation of resident care and safety.
Complaint Details
Complaint IN00439605 was substantiated with state deficiencies cited at R0090 and R0217 related to bruising of unknown origin and failure to separate cognitively impaired residents as requested by family.
Deficiencies (2)
| Description |
|---|
| Failed to ensure the Executive Director or Health Wellness Director reported bruising of unknown origin and an incident with law enforcement to the Indiana Department of Health. |
| Failed to keep cognitively impaired residents separated from each other as requested by female family members. |
Report Facts
Residents affected: 2
Residential Census: 51
Survey date: Aug 15, 2024
Plan of Correction Completion Date: Feb 28, 2025
Plan of Correction Completion Date: Sep 30, 2024
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 7
Jun 12, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00433770.
Findings
The facility was found deficient in multiple areas including employing an unlicensed CNA, failure to provide proper employee orientation and inservice training, unsafe food handling practices, failure to conduct appropriate fall risk assessments and interventions for a resident with repeated falls, failure to wear hairnets in the kitchen, and failure to properly label and remove expired medications.
Complaint Details
Complaint IN00433770 - State deficiencies related to the allegations are cited at R0215, including failure to provide appropriate fall prevention interventions for Resident B who sustained multiple falls and a hip fracture.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure all Certified Nursing Aides were licensed while working with residents; CNA 10 worked 41.5 days with an expired license. |
| Facility failed to ensure general and/or specific orientation was provided to employees upon hire for 1 of 5 employee records reviewed. |
| Facility failed to ensure employee initial education was completed during the hiring process for 2 of 5 employee records reviewed. |
| Facility failed to thaw meat per policy, remove spoiled milk from refrigerator, and date opened food items in the refrigerator. |
| Facility failed to ensure a resident with a history of repeated falls received appropriate assessments, goals, and interventions to prevent continued falls. |
| Facility failed to ensure kitchen staff wore hairnets during food preparation. |
| Facility failed to date medications when opened and failed to remove expired medications from use in medication rooms. |
Report Facts
Residents affected by unlicensed CNA: 45
Days CNA worked with expired license: 41.5
Number of falls Resident B sustained: 21
Number of employees reviewed for orientation: 5
Number of employees missing initial education: 2
Number of kitchen observations: 1
Number of medication rooms reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Aide | Worked with expired license for 41.5 days. |
| Executive Director | Interviewed regarding expired CNA license and fall management. | |
| Business Office Manager | Informed CNA 10 of expired license and was unaware CNA could not work without a license. | |
| Qualified Medication Aide 14 | Missing orientation record upon hire. | |
| Qualified Medication Aide 15 | Missing resident rights and abuse education documentation. | |
| Concierge 16 | Missing abuse education documentation. | |
| Resident B's wife | Provided detailed interview about Resident B's falls and care concerns. | |
| Previous Director of Nursing | Involved in care planning and fall management for Resident B; failed to notify Executive Director of falls and x-ray results. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Apr 24, 2024
Visit Reason
This visit was conducted to investigate two residential complaints, IN00429679 and IN00429693, at Woodland Terrace of Danville.
Findings
No deficiencies related to the allegations in complaints IN00429679 and IN00429693 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Residential Complaints IN00429679 and IN00429693 found no deficiencies related to the allegations.
Report Facts
Residential Census: 48
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Apr 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404530.
Findings
No deficiencies related to the allegations in Complaint IN00404530 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00404530 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 41
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Jan 13, 2023
Visit Reason
This visit was for the investigation of Complaint IN00398524.
Findings
Complaint IN00398524 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00398524 - Unsubstantiated due to lack of evidence.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Nov 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395128.
Findings
The complaint IN00395128 was found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00395128 was unsubstantiated due to lack of evidence.
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