Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Gideon Care Center during CMS and state inspections, most recent first.
Failure to accommodate resident needs and preferences: A resident with COPD had an oxygen concentrator that repeatedly beeped and was not replaced despite the resident reporting poor sleep, frustration, and anxiety. In the dining room, a resident with dementia and weakness and another resident said the table was too high and made it hard to reach food, while a resident with dementia, DM, CKD, and COPD was observed with the call light on the floor out of reach despite needing staff help.
A resident was discharged from skilled Medicare services without documentation that a SNF ABN was issued to the resident or representative at least 2 calendar days before services ended. The facility policy required written notice when Medicare payment denial or a change in coverage was likely, but the record contained no SNF ABN. The Administrator said she assumed the notice was not provided and signed because she could not find one, and stated it must have been missed by Social Services Designees.
Failure to Post Required Daily Nurse Staffing Information: The facility did not post the required daily nurse staffing information in a prominent location accessible to residents and visitors for 3 of 4 observed days. The Staff Posting Sheet across from the nurse's station was missing the required licensed and unlicensed nursing staff counts and actual hours worked. An LPN said each shift was responsible for completing the sheet, and the DON and Administrator stated the sheet should include the staff worked and total hours worked.
The facility failed to accurately document, dispose of, and reconcile controlled substances for two residents. An unlocked narcotic lock box was found in a medication refrigerator with lorazepam bottles whose remaining amounts did not match the narcotic count log, and a morphine bottle in the medication cart also did not match the recorded count. The DON said staff should lock the box after counting and report discrepancies immediately, while an LPN said the count was off but had not yet informed the DON.
Failure to follow EBP and wound care infection control was observed for a resident with diabetes and two left leg wounds. Staff inconsistently used PPE, one LPN entered without a gown, hand hygiene was not performed after glove changes, and ointment was applied directly with a gloved finger instead of a no-touch method. The dressing was also not dated and initialed, and no EBP signage was posted outside the room.
A facility failed to consistently document a resident's code status, leading to conflicting information in the medical records. The resident's face sheet indicated CPR status, while other documents suggested a DNR status. Interviews with staff and the resident highlighted the inconsistency, with the resident expressing a preference for DNR. The Director of Nursing and Administrator acknowledged the need for consistent documentation.
The facility failed to maintain a safe, clean, and homelike environment, with observations of peeled paint, exposed sheetrock, non-functioning light fixtures, and buildup of dirt and spider webs. Despite the facility's policy, these issues were not documented in the maintenance log, and interviews revealed a lack of communication and follow-up on environmental concerns, potentially affecting all 60 residents.
The facility failed to implement comprehensive care plans with specific interventions for five residents. One resident's care plan did not address pressure ulcers, while three residents admitted to hospice care lacked hospice-related interventions. Another resident's care plan inaccurately required smoking supervision despite an assessment indicating it was unnecessary. The Administrator acknowledged the expectation for care plans to reflect residents' care needs.
The facility failed to obtain a physician order for hospice services for a resident and did not adhere to prescribed insulin administration times for multiple residents. Interviews confirmed that insulin should be administered shortly before meals, and a physician order is expected for hospice services. These deficiencies highlight lapses in following physician orders and facility policies.
The facility failed to provide ordered restorative nursing services to residents with limited ROM, resulting in missed sessions for three residents. Despite orders for restorative care three times a week, residents experienced numerous missed opportunities due to staff being reassigned to other duties. Interviews with staff revealed an expectation for services to be provided, but documentation was lacking.
The facility failed to label and date food items and maintain temperature logs, increasing the risk of food-borne illness for all residents. Observations showed unlabeled and undated food in various storage areas and incomplete temperature logs. Interviews confirmed lapses in adherence to food safety policies, with staff acknowledging missing records and unresolved maintenance issues.
The facility failed to implement proper infection control practices during medication administration through a PICC line and did not adhere to enhanced barrier precautions and hand hygiene during incontinent and catheter care for residents. Staff did not follow facility policies, leading to potential risks of infection spread among residents.
The facility did not document the provision of education on the benefits and side effects of influenza and pneumococcal vaccines for four residents. Despite the facility's policy requiring such documentation, records showed no evidence of education being provided before vaccine administration or refusal. Interviews with the ADON and DON confirmed this oversight.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not replacing an oxygen concentrator for a resident with chronic respiratory conditions, by not adjusting dining table height for residents during meals, and by not keeping a call light within reach for a resident who needed assistance. The report identified these issues through observation, interview, and record review for residents in and outside the sample. Resident #18 was admitted with pneumonia, chronic respiratory failure, hypoxia, anxiety disorder, and COPD. The resident had orders for oxygen at 4 L per minute via nasal cannula and for cleaning and maintenance of the oxygen concentrator and tubing. During observations, the resident’s oxygen concentrator made a loud continuous beeping sound multiple times while in bed, in the activities room, and at the bedside. The resident repeatedly turned the concentrator off and back on to stop the beeping. In interview, the resident said the concentrator had kept him/her up at night for over a week, was beeping about every 30 minutes, and was very frustrating and anxiety-provoking. Staff interviews showed that a beeping concentrator should be reported to the charge nurse and replaced if needed, and the DON stated the facility should always have a spare concentrator. The maintenance repair log did not address the resident’s concentrator concern. Resident #31 had diagnoses including dementia, heart failure, chronic kidney failure, and weakness. During observations in the dining room, the resident sat in a wheelchair at the table with his/her arms and shoulders below table level and had difficulty reaching food to eat. Another resident, Resident #42, said the table was a little too high and sometimes made it difficult to reach food served. Staff also stated the tables looked too tall for some residents and appeared to have adjustable legs. In addition, Resident #54, who had diagnoses including type II DM, chronic kidney failure, dementia, and COPD and required staff assistance with ADLs, was observed in bed with the call light lying on the floor out of reach. The resident said the call light was used to request staff help and to go to the restroom. Multiple staff members and the DON stated call lights should always be within reach of residents.
Failure to Issue SNF ABN Before End of Skilled Medicare Services
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) in writing at least two calendar days before a resident was discharged from skilled Medicare services. The deficiency affected one resident out of three sampled residents, and the resident remained in the facility after discharge from skilled services on 01/24/26. The record review showed no documentation that the resident or the resident's representative received a SNF ABN. The facility's policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated September 2024, stated that Medicare beneficiaries are to be informed in advance and in writing when Medicare payment denial or a change in coverage is likely, and that a SNF ABN CMS Form 10055 is to be issued before care that Medicare usually covers may not be paid for under the current circumstance. During interview, the Administrator stated she assumed a SNF ABN was not provided and signed because she could not find one, and said it must have been missed by the Social Services Designees.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for three of four observed days. The census was 62. Review of the facility policy titled, "Posting Direct Care Daily Staffing Numbers," dated August 2022, showed the facility was to post, within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care, along with the total number of staff and actual hours worked. Observations of the Staff Posting Sheet, located on a window across from the nurse's station, showed the required daily nurse staffing information was not posted for 03/16/26, 03/17/26, and 03/18/26. During interviews, an LPN said each shift was responsible for filling out the staffing sheet with the hours worked and the staff worked. The DON said she expected each nurse on each shift to completely fill out the staffing sheet as soon as they arrived, including the staff hours worked and the total hours for each shift. The Administrator also said the nurses should be filling out the staffing sheet completely with the actual staff worked and the total hours worked.
Medication Reconciliation and Controlled Substance Documentation Failure
Penalty
Summary
The facility failed to implement procedures to ensure medications were accurately documented, disposed of, and reconciled for two residents. During observation of the 300 Hall medication room refrigerator, an unlocked narcotic lock box was found inside the refrigerator with two opened bottles of lorazepam for two residents. The observed amounts remaining in the bottles did not match the narcotic count log: one resident’s lorazepam bottle had 16 ml remaining while the log showed 20 ml remaining, and the other resident’s bottle had 18 ml remaining while the log showed 22.5 ml remaining. The facility policy required controlled substances to be separately locked and for the oncoming and off-going nurses to count together and document discrepancies. During interview, the DON said nurses should lock the narcotic lock box before returning it to the refrigerator after counting medications and stated she was unaware the narcotic count was off. She also said that if a resident refused a dose of a narcotic, a waste form should be completed, but staff did not fill them out as they should and she had no follow-up process for refusals or wasting medications. An LPN stated he counted the narcotics with an RN at shift change, knew the count was off for the two residents, but had not yet informed the DON, and said he normally locked the narcotic lock box back but must have forgotten. In a separate observation, a bottle of morphine for one resident in the medication cart showed 20 ml remaining, while the narcotic count log showed 26 ml remaining.
Failure to Follow EBP and Wound Care Infection Control
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) and infection control practices during wound care for one resident with left leg wounds. The resident had diagnoses including type 2 diabetes mellitus, acquired absence of the right leg above the knee, hypertension, anxiety, and depression. The resident’s physician orders directed staff to cleanse and dress two left leg wounds three times daily, including application of gentamicin ointment and dressing changes. During observation of wound care, staff placed EBP supplies outside the resident’s door, but no EBP signage was posted. On multiple observations, an LPN and an RN entered the room with varying PPE use, including one instance where an LPN did not put on a gown before entering. Staff removed soiled dressings, cleaned the wounds, and changed gloves at times, but hand hygiene was not performed after glove changes as observed. Staff also applied gentamicin ointment directly with a gloved finger rather than using a no-touch technique, and did not perform hand hygiene or change gloves between wound applications. The wound care observations also showed that the dressing was applied without dating and initialing it. Interviews with staff and leadership indicated they understood EBP was required for residents with wounds and that gown and gloves should be used for wound care, with hand hygiene after glove changes. The DON and Administrator stated they expected staff to use a cotton-tipped applicator or tongue depressor when applying ointments or creams to wounds.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to obtain a physician's order for a resident's code status and to consistently document the code status across the resident's medical records. This deficiency was identified for one resident out of a sample of 15, in a facility with a census of 60. The resident's medical record showed conflicting information: a CPR code status on the face sheet, a red dot indicating DNR on the hard chart, and a red sheet labeled DNR. Additionally, an Outside the Hospital Do Not Resuscitate Order was signed by both the resident and the attending physician. However, the Physician Order Sheet contained an order for CPR status, creating inconsistency in the documentation. Interviews with the resident and staff revealed further discrepancies. The resident expressed a desire for a DNR status and mentioned signing a document to that effect. A registered nurse indicated that they would check the electronic medical record for the resident's code status, while the Director of Nursing and the Administrator both acknowledged that the code status should be consistent across all records. This inconsistency in documentation and failure to obtain a proper physician's order for the resident's code status led to the identified deficiency.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. These included areas of peeled paint and exposed sheetrock in various rooms, non-functioning ceiling light fixtures in the women's bath area, and a buildup of dirt, debris, and spider webs in several locations, including the main entrance and exit doors of different halls. The facility's policy on maintaining a homelike environment was not adhered to, as these conditions were not documented in the maintenance log, and no corrective actions were noted. Interviews with housekeeping staff and the Maintenance Supervisor (MS) revealed a lack of communication and follow-up on environmental concerns. Housekeepers reported writing down issues in the maintenance log and verbally informing the MS, but no recent concerns were noted. The MS and the Administrator expected staff to document and report issues, yet the maintenance log showed no recorded concerns during the specified period. This lack of documentation and follow-up contributed to the ongoing environmental deficiencies, potentially affecting all 60 residents in the facility.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans with specific interventions for five residents, as required by their policy. Resident #36's care plan did not address interventions for pressure ulcers, despite having diagnoses of muscle weakness, COPD, and pressure ulcers at stages 2 and 3. Residents #38, #41, and #48, who were admitted to hospice care, had care plans that did not include interventions related to their hospice admission. These residents had various diagnoses, including Alzheimer's disease, major depressive disorder, hypertension, hypothyroidism, diabetes mellitus, hyperlipidemia, generalized anxiety, psychosis, cerebral infarction, vascular dementia, atrial fibrillation, hemiplegia, and dysphagia. Resident #56's care plan inaccurately required supervision while smoking, despite an IDT assessment determining the resident was safe to smoke without supervision. The care plan had not been updated to reflect this assessment. During an interview, the Administrator acknowledged that she would expect the care plan to reflect the resident's care needs, including hospice admission. The facility's failure to update and implement care plans with specific interventions for these residents indicates a deficiency in meeting the residents' individual needs.
Deficiencies in Physician Orders and Insulin Administration
Penalty
Summary
The facility failed to obtain a physician order for hospice services for a resident admitted to hospice care. The resident, diagnosed with Parkinson's Disease, hypertension, and osteoarthritis, was admitted to hospice on March 10, 2024. However, the physician order for hospice services was not present in the resident's December 2024 Physician Order Sheet, and the hospice admission order was not signed and dated by a physician, only by a hospice RN. Additionally, the facility did not adhere to prescribed insulin administration times for several residents. One resident with diagnoses of systolic congestive heart failure and diabetes mellitus had multiple instances where Novolin R insulin was administered significantly later than the ordered times. Another resident with dementia, dysphagia, and diabetes mellitus also experienced delays in receiving Fiasp insulin according to the sliding scale order. A third resident with hypertensive heart, chronic kidney disease, and diabetes mellitus had similar issues with delayed administration of Fiasp insulin. Interviews with the Director of Nursing and the Administrator confirmed that insulin should be administered shortly before meals, ideally 10-15 minutes prior. The Director of Nursing also acknowledged the expectation for a physician order for hospice services for residents receiving such care. These deficiencies highlight lapses in following physician orders and facility policies regarding timely medication administration and proper documentation for hospice care.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility staff failed to provide appropriate restorative nursing services to residents with limited range of motion (ROM), as evidenced by missed opportunities for scheduled restorative care. Three residents, identified as Residents #23, #30, and #35, did not receive the ordered restorative services intended to maintain or improve their ROM. The facility's policy mandates that residents receive individualized restorative nursing care to promote safety and independence, yet this was not consistently implemented. Resident #23, diagnosed with generalized muscle weakness and gait impairment, was ordered to receive restorative nursing services three times a week. However, documentation revealed numerous missed sessions over a three-month period, with 10 missed opportunities in October, six in November, and four in December. Similarly, Resident #30, who is dependent for all activities of daily living and has impairments in both upper and lower extremities, also experienced missed restorative sessions, with nine missed in October, five in November, and four in December. Resident #35, with diagnoses including dementia and stroke, also had missed restorative sessions, with six missed in October, three in November, and four in December. Interviews with facility staff, including a Restorative Nurse Aide (RNA) and the Director of Nursing (DON), revealed that the RNA was often reassigned to other duties, such as assisting with transports and showers, which contributed to the missed restorative sessions. The DON and the facility Administrator both expressed an expectation that residents should receive the restorative services as ordered, but there was a lack of documentation to confirm whether services were provided when the RNA was reassigned. This deficiency highlights a failure in the facility's ability to consistently deliver necessary restorative care to residents as per their care plans.
Food Safety and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to its food safety policies, resulting in several deficiencies related to food labeling, dating, and temperature monitoring. Observations revealed multiple instances of food items in the stand-up refrigerator, walk-in refrigerator, and walk-in freezer that were not labeled or dated, including sausage biscuits, a container of soup, a bag of ham, and opened sausage patties. Additionally, the chest freezer temperature logs were incomplete, with missing entries for several days. These practices increased the risk of cross-contamination and food-borne illness for all 60 residents in the facility. Interviews with the Dietary Manager and staff confirmed that the facility's policy required food to be labeled and dated upon opening, and temperatures to be checked and recorded daily. However, the Dietary Manager acknowledged awareness of missing temperature records and the ongoing issue of a leaking pipe under the triple sink, which had been unresolved since March 2024. Dietary staff also confirmed their responsibility for ensuring food was properly labeled and dated, and for maintaining temperature logs, but admitted to lapses in these duties. The Administrator expressed expectations aligned with the facility's policy but was unaware of the leaking pipe issue.
Infection Control Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during the administration of medications through a peripherally inserted central catheter (PICC) for one resident. The staff did not follow the facility's policy for disinfecting the needleless access device before connecting or disconnecting the syringe, which is crucial to prevent infections. Additionally, the biohazard waste was not stored properly, with bags left on the floor and trash protruding from barrels, which could pose a risk of contamination. The facility also did not adhere to enhanced barrier precautions (EBP) and proper hand hygiene during incontinent care and catheter care for two residents. Staff members failed to perform hand hygiene before and after glove changes and did not use gloves and gowns as required by EBP guidelines. This lack of adherence to infection control protocols during high-contact care activities could increase the risk of spreading infections among residents. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of compliance with the facility's infection control policies. Staff members admitted to not performing hand hygiene between glove changes and not being familiar with EBP requirements. The facility's failure to ensure proper infection control practices and adherence to policies had the potential to affect all residents in the facility.
Failure to Document Vaccine Education
Penalty
Summary
The facility failed to document the provision of education regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines for four residents out of five sampled. The facility's policy, revised in October 2019, mandates that residents or their legal representatives be informed about the benefits and potential side effects of vaccinations, with this education documented in the resident's medical record. However, the records for Residents #7, #21, #30, and #56 showed no documentation of such education being provided, despite the administration or refusal of the influenza vaccine. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the lack of documentation. The ADON acknowledged that the facility did not document the provision of vaccine education in the medical records. The DON stated that the facility should be educating residents or their representatives about the risks and benefits of vaccines before administration, indicating a lapse in following the established policy.
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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 Gideon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Malden | 8.8 mi | ★★★★★ | 0 | 0 |
| Campbell Healthcare & Senior Living | 9.2 mi | ★★★★★ | 15 | 0 |
| Portageville Health Care Center | 12.7 mi | ★★★★★ | 0 | 0 |
| Winchester Nursing Center, Inc | 15.1 mi | ★★★★★ | 0 | 0 |
| Piggott Healthcare & Senior Living, Llc | 16.1 mi | ★★★★★ | 18 | 0 |
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