Independent · Federal inspection records, searchable
Not a law firm · Not a government agency
Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 145911

Goldwater Care Gibson City

73 federal citations on record , including 1 at the Immediate Jeopardy level, and 8 federal enforcement actions totaling $84,595.

Abuse Icon 1 Immediate Jeopardy

Record summary

Federal record · Q1 2026
73
Total citations
49
Last 3 years
7
Actual harm+
8
Federal penalties
$84,595
Total fines
1
Overall ★ rating

Most common violation categories here

Quality of Care25 Resident Rights10 Abuse & Neglect9 Infection Control8 Medication & Pharmacy7

Most common F-tags at this facility

F6895 F6004 F6774 F6903 F5503

Citation history

73 on record
SurveyF-TagViolationSeveritySource
Dec 23, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EComplaint
Dec 23, 2025F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.EComplaint
Dec 23, 2025F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Dec 23, 2025F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.EComplaint
Sep 14, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
May 8, 2025F610Respond appropriately to all alleged violations.DComplaint
May 8, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
May 8, 2025F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.DComplaint
May 8, 2025F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.GComplaint
May 8, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EComplaint
Mar 28, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.EStandard
Mar 28, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EStandard
Oct 23, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint
Oct 1, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint
Sep 26, 2024F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.FComplaint
Sep 26, 2024F760Ensure that residents are free from significant medication errors.JComplaint
Jul 9, 2024F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.EComplaint
Jul 9, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Jul 9, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EComplaint
Jul 3, 2024F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.FComplaint
Jul 3, 2024F946Provide training in compliance and ethics.FComplaint
Jul 3, 2024F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.FComplaint
Jul 3, 2024F610Respond appropriately to all alleged violations.FComplaint
Jul 3, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.FComplaint
Jul 3, 2024F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.GComplaint
Apr 24, 2024F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DComplaint
Mar 19, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DComplaint
Mar 19, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Mar 19, 2024F552Ensure that residents are fully informed and understand their health status, care and treatments.DComplaint
Feb 6, 2024F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
Feb 6, 2024F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.DStandard
Feb 6, 2024F759Ensure medication error rates are not 5 percent or greater.EStandard
Feb 6, 2024F695Provide safe and appropriate respiratory care for a resident when needed.EStandard
Feb 6, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Feb 6, 2024F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.DStandard
Feb 6, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Feb 6, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Feb 6, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Feb 6, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Feb 6, 2024F641Ensure each resident receives an accurate assessment.DStandard
Feb 6, 2024F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.DStandard
Oct 18, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint
Oct 18, 2023F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Oct 18, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Sep 1, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Aug 16, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint
Aug 16, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EComplaint
Jul 24, 2023F760Ensure that residents are free from significant medication errors.EComplaint
Jun 13, 2023F697Provide safe, appropriate pain management for a resident who requires such services.DComplaint
Feb 16, 2023F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.EStandard
Feb 16, 2023F888Ensure staff are vaccinated for COVID-19FStandard
Feb 16, 2023F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.EStandard
Feb 16, 2023F886Perform COVID19 testing on residents and staff.FStandard
Feb 16, 2023F885Report COVID19 data to residents and families.FStandard
Feb 16, 2023F883Develop and implement policies and procedures for flu and pneumonia vaccinations.EStandard
Feb 16, 2023F881Implement a program that monitors antibiotic use.FStandard
Feb 16, 2023F880Provide and implement an infection prevention and control program.FStandard
Feb 16, 2023F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Feb 16, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Feb 16, 2023F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.EStandard
Feb 16, 2023F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.EStandard
Feb 16, 2023F759Ensure medication error rates are not 5 percent or greater.EStandard
Feb 16, 2023F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.EStandard
Feb 16, 2023F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.EStandard
Feb 16, 2023F695Provide safe and appropriate respiratory care for a resident when needed.EStandard
Feb 16, 2023F692Provide enough food/fluids to maintain a resident's health.DStandard
Feb 16, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EStandard
Feb 16, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Feb 16, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Feb 16, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EStandard
Feb 16, 2023F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.DStandard
Feb 16, 2023F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.DStandard
Feb 16, 2023F565Honor the resident's right to organize and participate in resident/family groups in the facility.EStandard

Federal enforcement history

Federal regulators have imposed 8 enforcement actions against this facility, including 5 civil money penalties totaling $84,595 and 3 payment-denial actions spanning 101 days.

DateTypeFinePayment denial
Mar 28, 2025Payment Denial—May 31, 2025 · 33 days
Sep 26, 2024Fine$59,827—
Sep 26, 2024Payment Denial—Oct 22, 2024 · 2 days
Aug 14, 2023Fine$2,447—
Aug 7, 2023Fine$2,117—
Jul 24, 2023Fine$15,971—
Jul 24, 2023Payment Denial—Sep 12, 2023 · 66 days
Jul 17, 2023Fine$4,233—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

Concerned about care at Goldwater Care Gibson City?

An attorney who focuses on nursing-home abuse and neglect can review the facility's record with you — citation patterns, scope/severity levels, complaint-driven findings — and tell you whether the law recognizes what happened.

  • Consultation is free and confidential
  • You pay nothing unless there is a recovery
  • Your note is shared only with vetted plaintiff attorneys
Free · Confidential · Nationwide network
Free Consultation Request
Tell us about your family's situation
A plaintiff attorney will review your note and respond within one business day.