Cycle 1
Health 2025-03-28 · Fire 2025-03-28
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Gibson City, IL
Goldwater Care Gibson City
1-star overall rating with 2-star inspections with abuse icon flag with $84,595 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
620 East First Street, Gibson City, IL
(217) 784-4257
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Goldwater Care
Operator or chain grouping
Approved since
1996-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.53
CMS adjusted total nurse staffing hours
Case-mix index
1.84
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,639
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.05
Performance 20.94% · Measure score 1.05 · Achievement 1.05 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.18
Baseline 5.80% · Performance 6.59% · Measure score 4.18 · Achievement 4.18 · Improvement 0
Total nurse turnover
1.14
Baseline 56.90% · Performance 59.02% · Measure score 1.14 · Achievement 1.14 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.45 hours · Performance 2.68 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.27% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 4.35% · Lower 95% interval 5.85% |
| Discharge to community | 43.95% |
50.57%
6.6 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 37.88% · Lower 95% interval 31.69% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 58 · Denominator 58 |
| Falls with major injury | 1.72% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 58 |
| Discharge self-care score | 32.5% |
53.69%
21.2 pts worse
|
Numerator 13 · Denominator 40 |
| Discharge mobility score | 52.5% |
50.94%
1.6 pts better
|
Numerator 21 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 4 · Denominator 58 · Adjusted rate 5.08% |
| Healthcare-associated infections requiring hospitalization | 6.58% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 4.44% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 1.27% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 79 |
| Staff flu vaccination coverage | 32.65% |
42%
9.4 pts worse
|
Numerator 32 · Denominator 98 |
| Discharge function score | 52.5% |
56.45%
4 pts worse
|
Numerator 21 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 38.71% |
25.2%
13.5 pts better
|
Numerator 12 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.0
0.8 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
2.3
1.9 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
89.6%
6.9 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 98.0% · Q3 98.0% · Q4 98.1% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
91.6%
6.5 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.3%
1.8 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.0% · Q3 2.0% · Q4 1.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 88.2% |
50.3%
37.9 pts worse
|
11.4%
76.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 84.4% · Q3 87.5% · Q4 89.6% · 4Q avg 88.2% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
6.5%
3.1 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.1% · Q3 13.6% · Q4 9.3% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
18.5%
4.5 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 11.6% · Q3 13.0% · Q4 15.6% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
22.8%
6.6 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 16.7% · Q3 13.5% · Q4 16.7% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.4% |
17.2%
7.2 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
15.0%
1.5 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 7.5% · Q3 25.6% · Q4 0.0% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
21.3%
0.9 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 9.8% · Q3 21.1% · Q4 28.4% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
5.2%
2 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.7% · Q3 8.4% · Q4 5.9% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.1% |
68.8%
1.7 pts worse
|
81.7%
14.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 63.9% · Q2 82.0% · Q3 65.5% · Q4 48.1% · 4Q avg 67.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.3% |
14.0%
8.3 pts worse
|
12.0%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 21.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.0% |
63.0%
21 pts better
|
79.7%
4.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
26.2%
1.2 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 25.5% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-06 · Fire 2024-02-06
29 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
32 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-04-15
F · Potential for more than minimal harm
2025-03-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-15
F · Potential for more than minimal harm
2024-02-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-02-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-02-16
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-02-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-02-16
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-02-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-03-28
F · Potential for more than minimal harm
2023-02-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-28
F · Potential for more than minimal harm
2023-02-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-24
E · Potential for more than minimal harm
2025-12-23
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-12-24
E · Potential for more than minimal harm
2025-12-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-09-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-15
G · Actual harm
2025-05-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-05-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-05-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-03-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-03-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-31
G · Actual harm
2024-10-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-24
G · Actual harm
2024-10-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-02
J · Immediate jeopardy
2024-09-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-07-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-13
E · Potential for more than minimal harm
2024-07-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-13
D · Potential for more than minimal harm
2024-07-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-13
G · Actual harm
2024-07-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-07-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-07-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-07-03
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-07-03
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-07-06
F · Potential for more than minimal harm
2024-07-03
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-04-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-02-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-02-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-20
G · Actual harm
2023-10-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-09-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-04
G · Actual harm
2023-08-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-07-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-16
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-16
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-16
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-16
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-16
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-03-15
Penalties and ownership
What sits behind the stars
$0
2025-03-28
Payment Denial
Payment Denial · denial start 2025-05-31 · 33 days
33 day denial
$59,827
2024-09-26
Fine
Fine · fine $59,827
Fine
$0
2024-09-26
Payment Denial
Payment Denial · denial start 2024-10-22 · 2 days
2 day denial
$2,447
2023-08-14
Fine
Fine · fine $2,447
Fine
$2,117
2023-08-07
Fine
Fine · fine $2,117
Fine
$15,971
2023-07-24
Fine
Fine · fine $15,971
Fine
$0
2023-07-24
Payment Denial
Payment Denial · denial start 2023-09-12 · 66 days
66 day denial
$4,233
2023-07-17
Fine
Fine · fine $4,233
Fine
Ownership
Ali, Basil
Operational/Managerial Control · Individual
Bane, Linda
Operational/Managerial Control · Individual
David A Berkowitz Delta Trust
5% Or Greater Direct Ownership Interest · Organization
Goldwater Care Management LLC
Operational/Managerial Control · Organization
Katzenstein, Meir
5% Or Greater Direct Ownership Interest · Individual
Spector, Jennifer
Operational/Managerial Control · Individual
Tversky, Aaron
5% Or Greater Direct Ownership Interest · Individual
Yosef Meystel Delta Trust
5% Or Greater Direct Ownership Interest · Organization
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