Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gibson Health Opco Llc during CMS and state inspections, most recent first.
Infection control practices were not followed during a medication pass and wound care. An RN handled refused meds with bare hands and returned some to floor stock bottles instead of discarding them, and an LPN changed gloves during a dressing change without performing hand hygiene before putting on a new pair. The DON stated staff are expected to perform frequent hand hygiene and that meds should not be handled with bare hands.
A facility failed to implement a comprehensive care plan for a resident with an indwelling catheter, increasing infection risks. The care plan lacked specific interventions for catheter care, and staff interviews revealed a lack of understanding and documentation of catheter care. The DON confirmed no documentation of catheter care in the resident's records.
A resident received insulin without the pen being primed, contrary to facility policy and manufacturer's instructions. An LPN administered four units of insulin without priming the pen, which could lead to inaccurate dosing. The LPN admitted to forgetting this step due to nervousness, and the DON acknowledged differing opinions on the necessity of priming.
A facility failed to provide appropriate catheter care for a resident with an indwelling catheter, as required by their policy. The resident, who had urinary retention and a UTI, did not receive documented catheter care during several months. Staff interviews revealed a lack of understanding and adherence to the catheter care policy, with some believing care was only needed during monthly catheter changes. The DON confirmed the absence of documentation and stated the policy was to perform care monthly or as needed.
Infection Control Lapses During Medication Pass and Wound Care
Penalty
Summary
Medication handling during a medication pass for R47 failed to follow infection control practices. RN AA prepared R47's 9:00 AM medications and nutritional supplement and took them to the resident's room, where R47 refused them. RN AA then returned to the medication cart and, using ungloved hands, removed Colace 100 mg and two vitamin B12 tablets from the medication cup and placed them back into the floor stock bottles. The remaining medications were set aside to be discarded and taken to the DON office for disposal. When asked about the practice, RN AA acknowledged that handling medications with bare hands and returning them to floor stock bottles was not appropriate. Hand hygiene was not performed at the appropriate point during wound care for R4. During a dressing change to a stage 3 wound on the left first distal toe, LPN BB was observed using PPE appropriately and performing hand hygiene before donning gloves. After removing the old dressing, she removed her soiled gloves, donned a new pair without performing hand hygiene, and continued the dressing change. When asked about the omission, LPN BB stated that hand hygiene should have been performed prior to donning clean gloves. The DON stated that staff are expected to perform frequent hand hygiene and follow proper infection control practices, and that medications should not be handled with bare hands.
Failure to Implement Comprehensive Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with an indwelling catheter, which had the potential to increase the risk of infections. The facility's policy required a care plan that included measurable objectives and timeframes to meet the resident's needs. However, the care plan for the resident, who had multiple diagnoses including urinary retention and a urinary tract infection, did not address catheter care and treatment. The care plan only mentioned providing pericare after each incontinent episode, but lacked specific interventions for catheter care. Interviews with facility staff revealed a lack of understanding and documentation regarding catheter care. A CNA was unsure of what catheter care entailed, and an LPN stated that catheter care was performed only during catheter bag changes or as needed, with no documentation of such care since the previous year. The Director of Nursing confirmed the absence of documentation in the electronic medical records, indicating a failure to adhere to the facility's policy and professional standards of quality care.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to adhere to professional standards of quality during the administration of insulin to a resident, identified as R368. The deficiency was observed when a Licensed Practical Nurse (LPN) administered insulin using an insulin pen without priming it first, as required by both the facility's policy and the manufacturer's instructions. The facility's policy, revised in April 2024, clearly states that insulin pens must be primed before each use to prevent air from collecting in the insulin reservoir, which could lead to inaccurate dosing. The manufacturer's instructions also emphasize the importance of priming to ensure the pen is functioning correctly and to avoid administering too much or too little insulin. During the medication administration, the LPN checked the resident's blood sugar level, which was 243, and proceeded to administer four units of insulin as per the doctor's order. However, the LPN did not prime the insulin pen before administration, which was later admitted during an interview, citing nervousness as the reason for forgetting this crucial step. The Director of Nursing (DON) acknowledged the differing opinions on the necessity of priming insulin pens but agreed to review the facility's policies. This oversight had the potential to affect the resident's blood glucose level and negatively impact their quality of life.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with an indwelling catheter, as per the facility's Catheter Care Policy. The policy required catheter care to be performed every shift and as needed, but there was no documentation of such care being provided for the resident during October, November, and December 2024. The resident had multiple diagnoses, including urinary retention, a stage 3 pressure ulcer, and a urinary tract infection (UTI). Despite these conditions, the facility did not have orders to address catheter care every shift, and the Treatment Administration Records lacked documentation of catheter care and cleaning. Interviews with staff revealed a lack of understanding and adherence to the catheter care policy. A CNA was unsure of what catheter care entailed, and an LPN believed catheter care was only necessary during monthly catheter changes. The Director of Nursing confirmed the absence of documentation for catheter care in the resident's electronic medical record and stated that the policy was to perform catheter care once monthly or as needed. The deficient practice had the potential to increase the risks of infections for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gibson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warrenton Woods Of Journey Llc | 12.7 mi | ★★★★★ | 2 | 0 |
| Thomson Health And Rehabilitation | 16 mi | ★★★★★ | 8 | 0 |
| Pruitthealth - Old Capitol | 19.8 mi | ★★★★★ | 9 | 0 |
| Heritage Inn Of Sandersville Health And Rehab | 20.1 mi | ★★★★★ | 0 | 0 |
| Washington Co Extended Care Facility | 20.5 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.