Health inspection·March 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide timely call light response for four (R17, R38, R45, R206) of nine residents reviewed for call light response times in the sample list of 27. Findings include: On 3/25/25 at 9:00 am, R206 stated that R206 needed assistance from staff, and R206 was unsure why they took so long to come to R206's room. R206 stated sometimes R45 (R206's roommate) has to wait 45 minutes or more for staff to come and put R45 into bed. R206 stated that sometimes R206 will wheel down the hall to get staff to come and help R45. Facility Census documents R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture, and Muscle Wasting and Atrophy. R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score of 8, moderate cognitive impairment, and needs moderate assistance with showers/bathing. On 3/25/25 at 9:15 am, R45 stated that sometimes R45 has to wait 45 minutes or more for staff to come and help R45 into bed. R45 stated that R206, R45's roommate, will get staff to help R45. R45's Minimum Data Set (MDS) dated [DATE] documents R45's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and needs substantial/maximum assistance with showers/bathing. On 3/25/25 at 11:24am R38 stated that it takes staff to long to answer call lights sometimes. R38 stated that R38 needed assistance from staff to get transferred to the toilet. R38 stated that in more than one instance R38 has had an incontinent episode, due to waiting on staff to come toilet R38. R38 stated, R38 sometimes has to wait 30-40 minutes for staffs' assistance. Facility Census documents R38 was admitted to the facility on [DATE] and has the following medical diagnoses: Parkinson's Disease, Major Depressive Disorder, and Post-Traumatic Stress Disorder. R38's Minimum Data Set (MDS) dated [DATE] documents R38's Brief Interview for Mental Status (BIMS) score 15, cognitively intact and needs substantial/maximum assistance with showers/bathe. On 3/26/25 at 9:00am, a resident council meeting was held. During the meeting R206 stated it takes a long time for call lights to be answered, R206's roommate (R45) calls out, so R206 turns the call (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145911 Printed: 05/15/2026 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 145911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 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)