Health inspection·February 19, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a care planned fall intervention was implemented for one (R1) of three residents reviewed for accidents on a sample list of four. R1's Care Plan dated 2/5/26 documents R1 admitted to the facility on [DATE], with diagnoses of Parkinson's Disease with Dyskinesia, with Fluctuations, Asthma, Depression, Atrial Fibrillation, Anemia, Obstructive Sleep Apnea (Adult), Essential (Primary) Hypertension, Gastroesophageal Reflux Disease without Esophagitis, Polyosteoarthritis, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Protein-Calorie Malnutrition, and Dysphagia.R1's Care Plan dated 2/5/26 documents R1 needs assistance of at least one staff member for all daily living activities, that R1 has physical mobility impairment and is non-weight bearing, and that R1 is high risk for falls with intervention added on 6/19/25 of low bed and observe for resident to be positioned in the middle of the bed. The Care Plan also documents R1 is at high risk for bleeding due to anticoagulant use.R1's Minimum Data Sheet (MDS) section C dated 2/4/26 documents R1 is cognitively intact.R1's MDS section GG dated 2/5/26 documents R1 as totally dependent on staff for activities of daily living.R1's Unwitnessed Fall Report dated 1/25/26 documents R1 was found lying prone on the floor next to the bed at 1:30 AM. The Report documents R1 made a statement that R1 rolled out of bed, and did not hit R1's head, but had some pain in the chest area. The Report documents R1 was assessed and placed back in bed by mechanical lift.R1's Hospital Records dated 1/25/25 document R1 was found on the floor with time on the floor unknown, that R1 has severe Parkinson's with tremors and cannot get out of bed or ambulate on own and that R1 is on blood thinner but was not transported to hospital at the time R1 was found on the floor stating R1 had no pain. The Hospital Records document R1 complained of pain to mid substernal chest and right sided rib area. The Hospital Records document R1 was diagnosed with four acute right side rib fractures and was admitted to the hospital to control pain and monitor for bleeding related to blood thinner.R1's Computed Tomography Scan Report dated 1/25/26 documents acute anterior right 3rd through 6th rib fractures with old rib fractures noted as well.On 2/19/26 at 11:38 AM, V10 Certified Nursing Assistant (CNA), stated that she was the aide assigned to R1 the night of 1/25/26. V10 stated that at approximately 1:00AM she observed R1 in bed sleeping and then went down the hall to the nurse's station and ate lunch with the other CNA and two nurses on shift that night. V10 stated when they finished lunch, she started rounding on her residents and observed R1's feet on the ground from the doorway. V10 stated she found R1 lying on his left side using his right arm to prop himself up on the ground next to his bed. V10 stated R1 was upset stating he had been hollering for help, but no one came. V10 stated that she has never heard R1 yell before and that he struggles with speaking after his stroke. V10 stated R1 stated R1's chest hurt and V10 alerted the nurse and V12 Licensed Practical Nurse (LPN), V13 LPN, and V11 CNA came to R1's room. V12 took R1's vitals and assessed R1 for injuries and used a mechanical lift with a sling to place R1 back in bed. V10 stated that (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 02/19/2026 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)