Goldwater Care Gibson City

In the surveyor’s words

From the most serious findings on record at Goldwater Care Gibson City, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Sep 26, 2024

  Based 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. […]

• Actual harm, isolatedF600May 8, 2025

  Based 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. Findings include: The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. […]

• Actual harm, isolatedF689Oct 23, 2024

  Based 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. […]

• Actual harm, isolatedF689Oct 1, 2024

  Based 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. Findings include: The facility Transfers-Manual Gait Belt and Mechanical Lift Policy (revised 1/19/18) documents the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility will use mechanical lifting devices for the lifting and movement of residents. […]

• Actual harm, isolatedF600Jul 3, 2024

  Based 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. Findings include: The facility undated policy titled 'Abuse, Neglect and Misappropriation of Resident Property' documents Physical/mental-the facilities policy is that the resident has the right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, corporal punishment and misappropriation of resident property in… […]