The nursing home failed to ensure residents were free from significant medication errors. Cited September 2024 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: J
Nursing home report
GOLDWATER CARE GIBSON CITY
GIBSON CITY, IL · Medicare-certified · 60 beds
Needs attention
Abuse citationFor-profitChain member
Data as of July 1, 2026
1 of 5 overall
Goldwater Care Gibson City has a 1-star overall rating, with 1-star staffing and 2-star health inspection and quality ratings. Reported nurse staffing is below the federal benchmark (3.37 vs. 4.1 hours per resident per day), and it has $59,827 in fines in the last 24 months plus a recent abuse citation.
Facility ratings
Health inspections
Staffing
3.3658 hrs/resident/day
Quality measures
Last inspection: May 12, 2026Penalties, last 24 months: $59,827recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.3658.
Staffing detail
- Registered nurses
- 0.38
- Licensed practical nurses
- 0.72
- Nurse aides
- 2.26
- Weekend nursing
- 3.22
Hours per resident per day.
Total staff turnover: 52%
Registered nurse turnover: 36%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
11.4%17.5%Worsening
Residents with a fall causing major injury
2%4%Worsening
Residents with pressure ulcers (bedsores)
8.4%2.6%Improving
Residents with a urinary tract infection
2.1%0%Improving
Residents who lost too much weight
13.6%15.4%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
25.6%32.4%Worsening
Residents whose ability to walk got worse
—25%—
Long-stay residents on antianxiety or sleep medication
13%26.8%Worsening
Short-stay residents newly given an antipsychotic
—0%—
Residents with a long-term catheter
1.4%0%Improving
Residents with new or worsening incontinence
21.1%16.6%Improving
Residents with depressive symptoms
87.5%78%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—98.1%—
Long-stay residents given the pneumonia vaccine
98%68%Worsening
Short-stay residents given the seasonal flu vaccine
—84%—
Short-stay residents given the pneumonia vaccine
65.5%40.9%Worsening
What the inspectors found
The nursing home failed to protect residents from abuse and neglect by others. Cited May 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 600 — 42 CFR §483.12 — S/S: G
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited October 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to have an ongoing quality review group that finds problems and makes corrective plans. Cited September 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 867 — 42 CFR §483.75 — S/S: F
The home failed to promptly report suspected abuse, neglect, or theft and share the investigation results with the proper authorities. Cited July 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 609 — 42 CFR §483.12 — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 5 health deficiencies.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $59,827 was recorded.
Penalties & enforcement
On record with Medicare: 5 fines · $84,595 in total fines · 3 payment denials.
- 33 days
Medicare/Medicaid payment denial
Mar 28, 2025
- 2 days
Medicare/Medicaid payment denial
Sep 26, 2024
- $59,827
Federal fine
Sep 26, 2024
- $2,447
Federal fine
Aug 14, 2023
- $2,117
Federal fine
Aug 7, 2023
- 66 days
Medicare/Medicaid payment denial
Jul 24, 2023
- $15,971
Federal fine
Jul 24, 2023
- $4,233
Federal fine
Jul 17, 2023
Operator & ownership
Recent ownership change · Jul 1, 2023
Now operated by Goldwater Care Gibson City, previously Heritage Health- Gibson City.
- Ownership
- For profit - Corporation
- Chain
- Part of GOLDWATER CARE · 11 homes · 1.5 stars avg
- Occupancy
- 51.6 residents on an average day (86% of 60 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 29 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.