Goldwater Care Gibson City
GOLDWATER CARE GIBSON CITY in GIBSON CITY, IL — inspection on December 23, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
something like what are you doing and a lot of times cuss words are mixed up in R3's wording. R2 responded by hitting R3's arm. R3's MDS dated [DATE] documents R3 has severe cognitive impairment and have verbal and physical behaviors directed towards others 1-3 days during the 7 day review period.
On 12/22/25 at 12:19 PM V14 CNA stated V14 witnessed R2's/R3's altercation.V17 was pushing R3 through the doorway of the 200 hallway. R3 said hi to R2 as they passed. R2 took her fist and hit R3 in his right arm. V14 confirmed R3's actions were intentional and not by accident. R3 had no signs of injury. 3.) The facility's Abuse Investigation Checklist documents an allegation of verbal and physical altercation between R5 and R7, who both have Alzheimer's/Dementia. On 11/14/25 at 4:00 PM in the front lobby, R7 was yelling, R5 told R7 to shut up, and then R5 hit R7 on R7's right thigh, witnessed by V5 CNA. V5's statement documents R7 was in the front lobby yelling like R7 does, V5 heard R5 yell back and V5 went to separate R5 and R7. As soon as V5 got to them, R5 hit R7 on R7's right thigh which left a small red mark.
R5's MDS dated [DATE] documents R5 has severe cognitive impairment. R5's active care plan documents R5 is at risk for abuse/neglect and R5 can have aggressive behavior.
This care plan includes an intervention dated 4/26/25 documents if staff hear R5 raising her voice redirect R5 with coffee or snacks and encourage R5 to move away from whomever R5 is talking to or move the other resident away from R5.
R7's MDS 9/24/25 documents R7 is rarely/never understood and has poor recall and memory impairment.
On 12/22/25 at 8:54 AM R5 was self propelling her wheelchair down the 200 hallway.
Attempts were made to interview R5, who became increasingly agitated with conversation and R5 cursed at the surveyor. On 12/22/25 at 3:06 PM V5 CNA stated V5 witnessed R5's/R7's altercation. R7 yells a lot and can be loud, which triggered R5 who hit R7 with an open hand on R7's thigh initially causing a red mark. R7 yelled ow when it happened, but otherwise had no overall response/reaction and no other injuries. V5 stated R5 and R7 have yelled back and forth between each other so we try to keep them apart. V5 confirmed R5's actions were intentional and not accidental. V5 stated R5 was upset with R7 and told R7 to shut up, and V5 attempted to get to them to separate R5/R7 before R5 hit R7.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Gibson City
620 East First Street Gibson City, IL 60936
SUMMARY STATEMENT OF DEFICIENCIES
afternoon, R4's call light was on and R4 had been incontinent of feces. V12 stated V8, Certified Nurse's Aide (CNA), and V9, Certified Nurse's Aide (CNA), answered the call light and said they would be back to clean R4.
After 45 minutes, V11 cleaned R4 and assisted her to her wheelchair. V8 or V9 did not return.
On 12/22/25 at 12:00 PM, V11, a Certified Nurse's Aide (CNA) and R4's family member, stated, I was called in to work on 12/1/25, and R4's call light was on. I went in to change R4, and she had dried feces all over her. I scrubbed it off, but it caused R4 pain and made her skin red and irritated.
On 12/22/25 at 2:00 PM, V8 stated, I do remember that day, though I'm not sure of the exact date. By the time V9 and I got back to clean up R4, V11 had already done it.
On 12/23/25 at 10:00 AM, R4 was lying in her bed looking out the window. R4 appeared clean and appropriately groomed. R4 stated, I don't want to get the staff in trouble or anything, 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. R4 looked away and frowned. 2.) On 12/23/25 at 6:17 AM, 6:30 AM, 6:40 AM, and 6:45 AM, R12's call light was on. At 6:50 AM, R12's call light was no longer on. R12 was sitting on the side of her bed with her pants at her knees. R12 stated an unidentified housekeeper had answered her call light and told her she would get staff to help. R12 stated she had been waiting to use the bathroom, which was why her call light was on. R12 stated she has waited up to 45 minutes in the past, which has caused her to urinate in her pants due to waiting so long.
At 7:00 AM, V21, Certified Nursing Assistant (CNA), entered R12's room. V21 stated she and the other CNA, V31, were in another resident's room performing a full mechanical lift transfer. R12 told V21 that her call light had been on for at least 20 minutes, which she stated was a long time to wait when needing to use the bathroom. V21 assisted R12 to the bathroom, and R12 was wearing an incontinence brief.
At 7:10 AM, R12 stated she wears incontinence briefs so that when she is incontinent, her pants will not get wet. R12 stated she does not like waiting so long that it causes her to be incontinent, stating, It's awful.
R12's Minimum Data Set (MDS), dated [DATE], documents R12 as cognitively intact, occasionally incontinent of bowel and bladder, and requiring partial/moderate staff assistance for toileting hygiene and supervision/touch assistance for transfers. R12's active Care Plan documents that R12 receives diuretic therapy and has diagnoses of morbid obesity and complex pain syndrome.
On 12/23/25 at 7:07 AM, V21 stated that two CNAs are not enough for R12's hallway, describing it as a heavy hall. V21 stated mornings are busy completing showers, which can affect call light response times.
V21 stated there are 12–13 residents on the hall who require mechanical lift transfers with two staff.
V21 stated all staff are supposed to help answer call lights.
On 12/23/25 at 10:38 AM, V1, Administrator, stated that call lights should be answered timely and that all staff are expected to answer call lights so assistance can be provided. V1 confirmed that a 30–45 minute response time would not be considered timely for a call light or toileting request.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Gibson City
620 East First Street Gibson City, IL 60936
SUMMARY STATEMENT OF DEFICIENCIES
stated the primary physician would be asked to re-evaluate R2 to determine if the Celexa dosage could be increased back to the prior level due to the timing of the medication reduction and subsequent altercations.
On 12/23/25 at 8:00 AM, V1 confirmed that no new interventions were implemented following the altercation between R2 and R3 and that R2's care plan had not been updated.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Gibson City
620 East First Street Gibson City, IL 60936
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review the facility failed to ensure resident medical records are complete/accurate by failing to document resident to resident altercations and family and physician notifications for four of eight residents (R2, R3, R5, R7) reviewed for abuse in the sample list of 12. 1.) The facility's Abuse Investigation Checklist documents an allegation of a verbal and physical altercation between R2 and R3, both of whom have dementia/Alzheimer's disease. On 11/22/25 at 11:45 AM, R3 spoke to R2, and R2 struck R3 on R3's right arm.
The incident was witnessed by V14, Certified Nursing Assistant (CNA).V14's statement documents that V14 was pushing a resident into the dining room for lunch and came around the corner to observe R2 pushing a transfer chair. V15 (R3's family member) was pushing R3 in a wheelchair through the lobby and past R2. R3 asked R2 what R2 was doing, at which time R2 raised her fist and struck R3 on his right upper arm.V15's statement documents that R3 was very excited about the visit and that R3 sometimes uses incorrect words. As they passed from the lobby into the hallway, R3 yelled at R2 something like, What are you doing, with profanity sometimes mixed into R3's wording. R2 responded by striking R3's arm.R2's and R3's medical records do not include documentation of this altercation, nor documentation that their families and physicians were notified.On 12/22/25 at 1:24 PM, V16, Licensed Practical Nurse (LPN), confirmed she was the nurse for R2 and R3 at the time of the 11/22/25 altercation. V16 stated that documentation of altercations is completed at the discretion of V1, Administrator. V16 confirmed that documentation and physician/family notification would typically be recorded in a nursing note.2.) The facility's Abuse Investigation Checklist documents an allegation of a verbal and physical altercation between R5 and R7, both of whom have Alzheimer's disease/dementia. On 11/14/25 at 4:00 PM in the front lobby, R7 was yelling, R5 told R7 to shut up, and then R5 struck R7 on R7's right thigh.
The incident was witnessed by V5, Certified Nursing Assistant (CNA).V5's statement documents that R7 was yelling in the front lobby, as was typical behavior. V5 heard R5 yell back and went to separate R5 and R7. As soon as V5 arrived, R5 struck R7 on the right thigh, leaving a small red mark.R5's and R7's medical records do not include documentation of this altercation, nor documentation that their families and physicians were notified.On 12/22/25 at 1:50 PM, V1 stated there should be a nursing note documenting a brief summary of the incident, including physician and family notification. V1 stated there was no incident report completed for this altercation.The facility's undated Medical Record Policy documents that progress notes will indicate significant changes in resident condition when they occur, and nurses will document nursing notes including behaviors, physician notification, and family notification.
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