Goldwater Care Gibson City
620 East First Street · Gibson City, IL · 60936 · 2177844257
60 certified beds For profit - Corporation Chain: Goldwater Care
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $59,827 in fines in the last 24 months.
- 6 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$59,827 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.52 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.46 | 0.55–0.75 |
| Weekend hours / resident-day | 3.32 | ≈ weekday level |
| Nursing turnover / year | 48% | median 45% |
| Fines (3-yr window) | 5 · $84,595 |
Inspection citations (75 in the current record)
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Potential for harm · D March 20, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 19, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 20, 2026 · Quality of Life and Care
-
Potential for harm · E December 23, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 23, 2025 · found via complaint
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 December 24, 2025 · Quality of Life and Care
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Potential for harm · E December 23, 2025 · found via complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected December 24, 2025 · Quality of Life and Care
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Potential for harm · E December 23, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D September 14, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected September 15, 2025 · Resident Assessment and Care Planning
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Actual harm · G May 8, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 1, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E May 8, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 29, 2025 · Resident Rights
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Potential for harm · D May 8, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected July 1, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 8, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 3, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 8, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected July 1, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 28, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 31, 2025 · Resident Rights
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Potential for harm · E March 28, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 31, 2025 · Quality of Life and Care
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Actual harm · G October 23, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 24, 2024 · Quality of Life and Care
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Actual harm · G October 1, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 2, 2024 · Quality of Life and Care
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Immediate jeopardy · J September 26, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected September 27, 2024 · Pharmacy Service
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Potential for harm · F September 26, 2024 · found via complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected September 27, 2024 · Administration
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Potential for harm · E July 9, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 13, 2024 · Resident Rights
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Potential for harm · D July 9, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected July 13, 2024 · Quality of Life and Care
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Potential for harm · E July 9, 2024 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected July 13, 2024 · Nutrition and Dietary
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Actual harm · G July 3, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 6, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F July 3, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 6, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F July 3, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected July 6, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F July 3, 2024 · found via complaint
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected July 6, 2024 · Administration
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 28, 2025 | Payment Denial | 33 days |
| September 26, 2024 | Fine | $59,827 |
| September 26, 2024 | Payment Denial | 2 days |
| August 14, 2023 | Fine | $2,447 |
| August 7, 2023 | Fine | $2,117 |
| July 24, 2023 | Fine | $15,971 |
| July 24, 2023 | Payment Denial | 66 days |
| July 17, 2023 | Fine | $4,233 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145911 · certified since December 1, 1996. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.