Goldwater Care Gibson City

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

something like what are you doing and a lot of times cuss words are mixed up in Resident R3's wording. Resident R2 responded by hitting Resident R3's arm. Resident R3's MDS dated [DATE REDACTED] documents Resident 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 Resident R2's/Resident R3's altercation.V17 was pushing Resident R3 through the doorway of the 200 hallway. Resident R3 said hi to Resident R2 as they passed. Resident R2 took her fist and hit Resident R3 in his right arm. V14 confirmed Resident R3's actions were intentional and not by accident. Resident R3 had no signs of injury. 3.)

The facility's Abuse Investigation Checklist documents an allegation of verbal and physical altercation between Resident R5 and Resident R7, who both have Alzheimer's/Dementia. On 11/14/25 at 4:00 PM in the front lobby, Resident R7 was yelling, Resident R5 told Resident R7 to shut up, and then Resident R5 hit Resident R7 on Resident R7's right thigh, witnessed by V5 CNA. V5's statement documents Resident R7 was in the front lobby yelling like Resident R7 does, V5 heard Resident R5 yell back and V5 went to separate Resident R5 and Resident R7. As soon as V5 got to them, Resident R5 hit Resident R7 on Resident R7's right thigh which left a small red mark. Resident R5's MDS dated [DATE REDACTED] documents Resident R5 has severe cognitive impairment. Resident R5's active care plan documents Resident R5 is at risk for abuse/neglect and Resident R5 can have aggressive behavior. This care plan includes an intervention dated 4/26/25 documents if staff hear Resident R5 raising her voice redirect Resident R5 with coffee or snacks and encourage Resident R5 to move away from whomever Resident R5 is talking to or move the other resident away from Resident R5. Resident R7's MDS 9/24/25 documents Resident R7 is rarely/never understood and has poor recall and memory impairment.

On 12/22/25 at 8:54 AM Resident R5 was self propelling her wheelchair down the 200 hallway. Attempts were made to interview Resident R5, who became increasingly agitated with conversation and Resident R5 cursed at the surveyor. On 12/22/25 at 3:06 PM V5 CNA stated V5 witnessed Resident R5's/Resident R7's altercation. Resident R7 yells a lot and can be loud, which triggered Resident R5 who hit Resident R7 with an open hand on Resident R7's thigh initially causing a red mark. Resident R7 yelled ow when it happened, but otherwise had no overall response/reaction and no other injuries. V5 stated Resident R5 and Resident R7 have yelled back and forth between each other so we try to keep them apart. V5 confirmed Resident R5's actions were intentional and not accidental. V5 stated Resident R5 was upset with Resident R7 and told Resident R7 to shut up, and V5 attempted to get to them to separate Resident R5/Resident R7 before Resident R5 hit Resident R7.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Goldwater Care Gibson City

620 East First Street Gibson City, IL 60936

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

afternoon, Resident R4's call light was on and Resident 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 Resident R4. After 45 minutes, V11 cleaned Resident 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 Resident R4's family member, stated, I was called in to work on 12/1/25, and Resident R4's call light was on. I went in to change Resident R4, and she had dried feces all over her. I scrubbed it off, but it caused Resident 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 Resident R4, V11 had already done it.

On 12/23/25 at 10:00 AM, Resident R4 was lying in her bed looking out the window. Resident R4 appeared clean and appropriately groomed. Resident 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. Resident R4 looked away and frowned. 2.) On 12/23/25 at 6:17 AM, 6:30 AM, 6:40 AM, and 6:45 AM, Resident R12's call light was on. At 6:50 AM, Resident R12's call light was no longer on. Resident R12 was sitting on the side of her bed with her pants at her knees. Resident R12 stated

an unidentified housekeeper had answered her call light and told her she would get staff to help. Resident R12 stated

she had been waiting to use the bathroom, which was why her call light was on. Resident 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 Resident R12's room. V21 stated she and the other CNA, V31, were in another resident's room performing a full mechanical lift transfer. Resident 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 Resident R12 to the bathroom, and Resident R12 was wearing an incontinence brief.

At 7:10 AM, Resident R12 stated she wears incontinence briefs so that when she is incontinent, her pants will not get wet. Resident R12 stated she does not like waiting so long that it causes her to be incontinent, stating, It's awful. Resident R12's Minimum Data Set (MDS), dated [DATE REDACTED], documents Resident 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. Resident R12's active Care Plan documents that Resident 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 Resident 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Goldwater Care Gibson City

620 East First Street Gibson City, IL 60936

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Level of Harm - Minimal harm or potential for actual harm

stated the primary physician would be asked to re-evaluate Resident 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 Resident R2 and Resident R3 and that Resident R2's care plan had not been updated.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Goldwater Care Gibson City

620 East First Street Gibson City, IL 60936

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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 (Resident R2, Resident R3, Resident R5, Resident 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 Resident R2 and Resident R3, both of whom have dementia/Alzheimer's disease. On 11/22/25 at 11:45 AM, Resident R3 spoke to Resident R2, and Resident R2 struck Resident R3 on Resident 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 Resident R2 pushing a transfer chair. V15 (Resident R3's family member) was pushing Resident R3

in a wheelchair through the lobby and past Resident R2. Resident R3 asked Resident R2 what Resident R2 was doing, at which time Resident R2 raised her fist and struck Resident R3 on his right upper arm.V15's statement documents that Resident R3 was very excited about

the visit and that Resident R3 sometimes uses incorrect words. As they passed from the lobby into the hallway, Resident R3 yelled at Resident R2 something like, What are you doing, with profanity sometimes mixed into Resident R3's wording. Resident R2 responded by striking Resident R3's arm.Resident R2's and Resident 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 Resident R2 and Resident 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 Resident R5 and Resident R7, both of whom have Alzheimer's disease/dementia. On 11/14/25 at 4:00 PM in the front lobby, Resident R7 was yelling, Resident R5 told Resident R7 to shut up, and then Resident R5 struck Resident R7 on Resident R7's right thigh. The incident was witnessed by V5, Certified Nursing Assistant (CNA).V5's statement documents that Resident R7 was yelling in the front lobby, as was typical behavior. V5 heard Resident R5 yell back and went to separate Resident R5 and Resident R7. As soon as V5 arrived, Resident R5 struck Resident R7 on the right thigh, leaving a small red mark.Resident R5's and Resident 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.

Event ID:

Facility ID:

If continuation sheet