Health inspection·September 14, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate documentation of medications that was administered for 2 of 3 residents (R1,R2) reviewed for medication administration.Findings include: 1.R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Fibromyalgia, Morbid Obesity, Complex Regional Pain Syndrome, Major Depressive Disorder, HTN, Hypothyroidism, GERD, Anxiety Disorder and Barrett's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R1's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 8 hours as needed for severe pain.R1's Controlled Drug Receipt Record/Disposition Form dated August 29, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R1's Medication Administration Record (MAR) dated August 29, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.2. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Primary Osteoarthritis Right Knee, Type 2 Diabetes, Cellulitis of Left Lower Limb, Non-Pressure Ulcer Right Lower Leg, Ataxia, Difficulty in Walking, Pulmonary Hypertension, Non-ST Elevation Myocardial Infarction, Heart Disease, Venous Insufficiency, Chronic Embolism and Thrombosis of Deep Veins of Lower Extremity. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R2's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 4 hours as needed for severe pain. R2's Controlled Drug Receipt Record/Disposition Form dated September 8, 2025, at 5:00am, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R2's Medication Administration Record (MAR) dated September 8, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.The Facilities Medication Administration General Guidelines not dated documents: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after the have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the residents Medication Administration Record (MAR) directly after the medication was given. 3. When as needed (PRN) medications are administered the following documentation is provided: a) Date and time of administration, dose, route of administration and if applicable the injection site. d) signature or initials of person recording administration and signature or initials of person recording effect, if different from the person administering the (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 2 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 09/14/2025 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)