Goldwater Care Gibson City

Inspectors wroteBased on interview and record review the facility failed to implement its abuse prohibition policy by failing to timely report and investigate allegations of abuse and missing money for three of four residents (R25, R20, R27) reviewed for abuse in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse and misappropriation of property to the state survey agency and law enforcement for three of four residents (R20, R25, R27) reviewed for abuse in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to protect residents' right to be free from verbal and mental abuse by staff for two of four residents (R20, R25) reviewed for abuse in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's (R27) right to be free from misappropriation of funds for one of three residents (R27) reviewed for misappropriation of property in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of misappropriation of property for one of four residents (R27) reviewed for abuse in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two (R1, R2) of three residents reviewed for abuse in the sample list of 6.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to protect residents' right to be free from physical abuse by another resident. This resulted in R1's abuse by R2, R3's abuse by R2, and R7's abuse by R5. R1, R2, R3, R5, and R7 are five of eight residents reviewed for abuse in the sample list of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement interventions to address dementia related behaviors for four of eight residents (R2, R3, R5, R7) reviewed for abuse in the sample list of 12.

Inspectors wroteBased 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 (R2, R3, R5, 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 R2 and R3, both of whom have dementia/Alzheimer's disease. On 11/22/25 at 11:45 AM, R3 spoke to R2, and R2 struck R3 on 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 R2 pushing a transfer chair. V15 (R3's family member) was pushing R3 in a wheelchair through the lobby and past R2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide toileting assistance/incontinence care in a timely manner for two residents (R4, R12) of five residents reviewed for bowel and bladder in a sample list of 12. Findings Include: The facility's Call Light Policy, reviewed 2/2/18, states: Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. All residents who have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility at the bedside or another reasonably accessible location. All staff should assist in answering call lights. Nursing staff members shall go to the resident's room to respond to the call system and promptly cancel the call light when the room is entered. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to protect the residents right to be free from physical and verbal abuse by another resident. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13. This failure resulted in R1 abusing R2 causing R2 to experience psychosocial harm as evidenced by crying.

Inspectors wroteBased on interview and record review the facility failed to ensure residents' right to be treated in a dignified manner for three (R8, R9, and R10) of 12 residents reviewed for abuse in the sample list of 13.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13.

Inspectors wroteBased on interview and record review, the facility failed to timely report an allegation of resident to resident physical and verbal abuse to the state survey agency. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample of 13.

Inspectors wroteBased 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.

Inspectors wroteBased on the interview and record review, the facility failed to provide numerous showers as scheduled for two (R45, R206) of three residents who were reviewed for showers in the sample list of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision to prevent a fall for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in R1 falling and sustaining a laceration to R1's head requiring sutures. Finding Include: R1's Care Plan reviewed 9/25/24 includes the following diagnoses: Urinary Incontinence, Anxiety, Right Sided Hemiplegia, Osteoarthritis, Parkinson's Disease, and Dysphagia. This Care Plan also documents R1 is at risk for falls related to Gait and Balance Deficit, Incontinence, Poor Communication and Comprehension, Diagnosis of Parkinson's and History of Cerebral Vascular Accident with Right Sided Hemiparesis. This care plan also documents R1 has a physician's order for a Regular, Pureed Diet with Nectar Thick liquids. [...]

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident (R1) by mechanical lift from a geriatric chair to bed. This failure resulted in R1 being hit in the shoulder by the mechanical lift equipment causing a hematoma to R1's shoulder and R1's foot becoming caught in R1's geriatric chair causing a fracture. R1 is one of three residents reviewed for accidents in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders for a resident's anticoagulant medication (Warfarin/Coumadin) resulting in the resident receiving an increased anticoagulant dosage for 24 days. The facility also failed to monitor the resident's anticoagulant medication as recommended by the drug manufacturer guidelines. These failures affect one (R1) resident reviewed for anticoagulation therapy on a sample list of three residents. These failures resulted in R1 experiencing internal bleeding and dying.

Inspectors wroteBased on interview and record review the facility failed to utilize data to put a quality improvement program in place that would identify, intervene, and improve resident outcomes to address significant medication errors after learning of a significant medication error that resulted in resident harm. This failure has the potential to all 51 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to respond to call lights timely for five (R6, R7, R10, R9, R12) of 12 residents reviewed for call lights in the sample list of 17.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to serve meals at an appropriate or palatable temperature. This failure effects nine (R6, R7, R9, R10, R13, R14, R15, R16, and R17) of 17 residents reviewed for food on the sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to provide showers as scheduled for one (R10) of seven residents reviewed for Activities of Daily Living in the sample list of 17.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents' right to be free from mental and physical abuse by staff. R2 experienced physical pain and psychosocial harm including fear, feeling unsafe, crying and mental stress/worrying. R3 experienced mental abuse through crying, being upset and scared. These failures affect two (R2, R3) residents out of four residents reviewed for abuse in a sample list of eleven residents.

Inspectors wroteBased on interview and record review the facility failed to notify the Administrator and the Administrator failed to notify the State Agency timely of allegations of staff to resident abuse for two (R2, R3) residents. This failure affects all 60 residents residing in facility.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy by not immediately suspending two alleged perpetrators after mental and physical abuse allegations were made by one resident (R3). The facility failed to protect two additional residents (R2, R6) from said perpetrators after R3's allegation was made. The facility also failed to assess R2 and R3 after abuse allegations were made against two alleged perpetrators. These failures affect three residents (R2, R3, R6) and have the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide staff with Quality Assurance Performance Improvement (QAPI) training. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide staff with Ethics training. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure continued competency for nurse aides for at least twelve hours per year including dementia training and resident abuse prevention training for four nurse aides (V3, V13, V14, V25). This has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affects two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings Include: The facility's undated Abuse Policy documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse includes hitting, slapping, pinching, and kicking. The Resident Abuse Investigation Form dated 4/11/24 documents after the evening meal on 4/11/24, R1 wandered into R2's room uninvited. R2 asked R1 to leave the room. R1 refused to leave. R2 attempted to move around R1's wheelchair and exit the room when R1 hit her causing a skin tear. R2 then hit R1 in retaliation. R2 called for help and staff came and separated the two residents. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent for surgical debridement of wounds from a resident's representative for one of three residents (R1) reviewed for wounds on the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's representative of wounds for one of three residents (R1) reviewed for wounds in the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to complete an initial wound assessment on admission and obtain treatment orders, failed to complete wound treatments as ordered and failed to complete pressure ulcer interventions as ordered and as stated in the facility policy for one of three residents (R1) reviewed for pressure ulcers in the sample list of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to change and label oxygen tubing and humidifier bottles (R43, R45, R306), failed to properly maintain Continuous Positive Airway Pressure (CPAP) mask (R20) and failed to properly maintain and store nebulizer mask/tubing (R38). These failures affect five (R43, R45, R306, R20, R38) of five residents reviewed for respiratory care in the sample list of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications in accordance with manufacturer's instructions and physician's orders for three (R37, R42, R256) of seven residents reviewed for medication administration in the sample list of 37. This failure resulted in four medication errors out of 31 opportunities, resulting in a 12.9 % medication error rate.

Inspectors wroteBased on interview and record review the facility failed to provide a written, Notice of Medicare Non-Coverage notice, (NOMNC) for three (R51, R257, R258) of three residents reviewed for Medicare Non-Coverage notices from a total sample list of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Minimum Data Sets (MDS) were accurate to include oxygen use for two (R20, R38) of five residents reviewed for respiratory care in the sample list of 37.

Inspectors wroteBased on interview and record review the facility failed to have quarterly care plan meetings for two (R20, R42) of two residents reviewed for care plan meetings in the sample list of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide grooming per resident preference for one (R42) of one resident reviewed for activities of daily living in the sample list of 37.

Inspectors wroteBased on interview and record review the facility failed to follow physician's orders for insulin and notify the physician that insulin was held for one (R38) of five residents reviewed for unnecessary medications in the sample list of 37.

Inspectors wroteBased on observation, interview and record review the facility failed to provide wound care as ordered for one (R23) of two residents reviewed for wound care from a total sample list of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide restorative range of motion services for one (R42) of one resident reviewed for restorative services in the sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly secure urinary catheter tubing and drainage bags to ensure hygenic storage (R306, R256), intervene for a leaking urinary catheter, and provide hygenic catheter care (R23). R306, R256, and R23 are three of three residents reviewed for catheters in the sample list of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were labeled with resident's name and opened date for two (R29, R43) of two residents reviewed for medication storage in the sample list of 37.

Inspectors wroteBased on interview and record review, the facility failed to administer pneumococcal vaccines for two (R36 and R38) of five residents reviewed for vaccines in a sample list of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete fall risk assessments, thoroughly investigate a fall, and implement fall interventions for three (R1, R2, R6) of three residents reviewed for falls in the sample list of six. The facility also failed to safely transfer R1, resulting in R1 falling and sustaining a right ear laceration requiring sutures to close.

Inspectors wroteBased on interview and record review the facility failed to report a resident fall to the physician and resident representative for one (R6) of three residents reviewed for falls in the sample list six.

Inspectors wroteBased on interview and record review the facility failed to provide showers as scheduled for three (R1, R3, R4) of four residents reviewed for showers in the sample list of six.

Inspectors wroteBased on interview and record review, the facility failed to obtain and implement urinary catheter orders and document urinary output for one (R1) of two residents reviewed for urinary catheters in the sample list of five.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store raw poultry to prevent cross contamination. The facility also failed to ensure food preparation equipment was disposed of/replaced when worn, cracked or broken and failed to ensure hand hygiene was performed after removing gloves and donning new gloves during food preparation. These failures have the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control surveillance program that tracks/analyzes/monitors resident and employee illnesses to identify any trends and patterns, and failed to conduct surveillance of staff and resident COVID-19 (Human Coronavirus Infection) infections during an outbreak. This failure has the potential to affect all 54 residents residing in the facility. The facility also failed to ensure staff removed or disinfected personal protective equipment after the care of a COVID-19 positive resident (R15) and prior to caring for COVID-19 negative resident (R25), failed to conduct symptom monitoring and vital signs every four hours for COVID-19 positive resident (R28), and failed to ensure staff wore eye protection during a COVID-19 outbreak for R12.

Inspectors wroteBased on interview and record review the facility failed to ensure urine and wound cultures were obtained to ensure appropriate use of antibiotics. This failure has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify residents and resident representatives after two COVID-19 confirmed cases and provide cumulative updates. This failure has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents (R35, R38, R51, R23, R50, R255, R4, R18, R19, R39, R48, R42, R34, R30, R8, R29, R45) who had close contact exposure to COVID-19 (Human Coronavirus Infection) and employees were tested for COVID-19 during an outbreak in accordance with facility policy. This failure has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an employee was fully vaccinated for COVID-19 (Human Coronavirus Infection), and develop a policy for employee COVID-19 vaccination that includes a process for medical and religious exemptions, and additional precautions to mitigate the spread of COVID-19 for unvaccinated staff. This failure has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to act, follow-up, and resolve concerns discussed in the resident council meetings for four of four residents (R8, R50, R49, and R42) reviewed for resident council on the sample list of 46.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were developed and implemented for five residents (R2, R12, R26, R35, R44) reviewed for care plans on the sample list of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to investigate falls, determine the root cause of falls, implement interventions add interventions to resident's care plans for four of four residents (R6, R47, R13, R24) reviewed for falls in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to store respiratory tubing and equipment in a sanitary manner, failed to obtain a physician's order for oxygen, and failed to date tubing and humidification bottle for four of four (R23, R43, R44, and R18) residents reviewed for respiratory equipment on the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt alternatives prior to the use of bed rails and accurately complete a side rail assessment for five of five residents (R23, R24, R38, R44, and R2) reviewed for bed rails on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to identify targeted behaviors and nonpharmacological interventions attempt psychotropic medication reductions, document a rationale for not attempting medication reductions, develop a psychotropic medications care plan, and complete timely psychotropic assessments for five of five residents (R8, R38, R45, R6, and R49) on the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of three residents (R105, R22) reviewed for medication administration in the sample list of 46. The facility had 4 medication errors out of 26 opportunities resulting in a 15.38% (percent) medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to store medications separately from food. This failure affects 20 residents (R26, R1, R12, R44, R47, R43, R19, R28, R5, R22, R30, R10, R25, R50, R46, R17, R45, R33, R35, R51) with medications in the refrigerator.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve residents meals as per the dietary spreadsheet. This failure affects seven residents (R9, R15, R21, R28, R48, R51, R255) reviewed for dietary food service on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to offer influenza and pneumococcal vaccinations, obtain/track resident influenza and pneumococcal vaccination information and document the information in the resident's medical record for four (R255, R50, R48, R6) of five residents reviewed for immunizations in the sample list of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to offer a COVID-19 (Human Coronavirus 2019) primary and booster vaccines, and obtain resident COVID-19 immunization information for four of (R255, R50, R48, R6) of five residents reviewed for immunizations in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to inspect bed rails to identify areas of entrapment, failed to ensure bed rails were secured to the bed frame, and failed to ensure the mattress fit securely against the side rails for five of five residents (R23, R24, R38, R44, and R2) reviewed for bed rails on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to accurately record a resident's preference for life-sustaining treatment in the medical record for one resident (R6) and failed to obtain a Qualified Practitioner's signature for a resident's POLST (Practitioner Order for Life-Sustaining Treatment) form for one resident (R49). This failure affects two (R6, R49) of three residents reviewed for advance directives in the sample list of 46.

Inspectors wroteBased on interview and record review, the facility failed to document written notification/acknowledgement of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for three of three residents (R18, R24, R52) and failed to document acknowledgement of Notice of Medicare Non-Coverage for one of three residents (R18) reviewed for beneficiary protection notification on the sample list of 46.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete skin assessments and assess and document a blood filled blister to the left hand little finger for one of one resident (R15) reviewed for skin alterations/edema on the sample of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete weekly pressure ulcer assessments, ensure a wound dressing was dated and intact, perform hand hygiene and prevent cross contamination during a pressure ulcer treatment for one resident (R26) reviewed for pressure ulcers in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a frozen nutritional supplement as ordered for two residents (R2, R12) reviewed for nutrition in the sample list of 46.

Inspectors wroteBased on interview and record review, the facility failed to ensure orders for hospice services were transcribed to residents Physician's Orders in the Electronic Medical Record and failed to ensure facility care plans were comprehensive for hospice services. These failures affect two of five residents (R26, R44) reviewed for hospice on the sample list of 46.