Goldwater Care Gibson City: Call Light Failures - IL
That was December 1, 2025, at Goldwater Care Gibson City, a nursing home on East First Street in this central Illinois town. The resident, identified in inspection records only as R4, had pressed her call light. Two CNAs answered it, told her they would be back to clean her up, and left. Forty-five minutes passed.
It was another CNA, V11, who finally came. V11 also happened to be R4's family member, called in to work that day. What she found required scrubbing. "She had dried feces all over her," V11 told inspectors on December 22. "I scrubbed it off, but it caused R4 pain and made her skin red and irritated."
One of the two CNAs who had walked away, identified as V8, told inspectors she remembered the incident. Her explanation: "By the time V9 and I got back to clean up R4, V11 had already done it."
When inspectors spoke with R4 herself the following morning, she was lying in bed, looking out the window. She appeared clean. She did not want to cause trouble.
"I don't want to get the staff in trouble or anything," she said, "but I do lay here sometimes all night in pee and poop. It is not their fault. I don't think they have enough help sometimes. It makes me feel uncomfortable, and it's kind of disgusting."
She looked away and frowned.
R4's account, offered without complaint, described a pattern, not a single incident. Lying in waste through the night. Discomfort she had apparently accepted as routine.
The same inspection, conducted December 23, 2025, documented a second resident facing the same problem the same morning inspectors were on-site.
At 6:17 a.m., R12's call light came on. It came on again at 6:30. At 6:40. At 6:45. At 6:50, the light went off, but not because anyone had helped her. A housekeeper had answered the light and told R12 she would send staff. Nobody came.
When inspectors checked at 6:50, R12 was sitting on the side of her bed with her pants at her knees. She had been waiting to use the bathroom. She told inspectors she has waited as long as 45 minutes in the past, long enough that she has urinated in her pants before staff arrived.
R12 is cognitively intact, her records show. She takes a diuretic, a medication that increases the urgency and frequency of urination. She has morbid obesity and complex pain syndrome. Getting to the bathroom is not something she can manage alone. Her care plan requires staff assistance for toileting.
She wears incontinence briefs, she explained to inspectors, not because she is incontinent by nature, but as a contingency for exactly these situations. "She does not like waiting so long that it causes her to be incontinent," the inspection report notes. Her own word for it: "It's awful."
A CNA named V21 arrived at 7:00 a.m. and helped R12 to the bathroom. V21 was direct with inspectors about why the wait had happened. She and the one other CNA assigned to R12's hallway had been occupied with a mechanical lift transfer in another room. That hallway has 12 to 13 residents who require two-staff mechanical lifts. Two CNAs. Mornings are consumed by showers. "It's a heavy hall," V21 said.
V21 added that all staff are supposed to help answer call lights, not just the CNAs assigned to a given hallway.
The facility's administrator, identified as V1, confirmed to inspectors that a 30 to 45 minute response time for a call light or toileting request would not be considered timely. Call lights should be answered promptly, V1 said, and all staff are expected to respond.
The deficiency was cited at a level of minimal harm or potential for actual harm.
R4 did not file a complaint. She vouched for the staff. She blamed the staffing. Then she looked away.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Gibson City from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
GOLDWATER CARE GIBSON CITY in GIBSON CITY, IL was cited for violations during a health inspection on December 23, 2025.
That was December 1, 2025, at Goldwater Care Gibson City, a nursing home on East First Street in this central Illinois town.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.