Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to promptly act upon recommendations of the
resident council group residents and failed to demonstrate the facility response to group recommendations
for six residents (R10, R15, R38, R45, R56, R123) in the sample of 33.
Residents Affected - Some
Findings include:
Facility Dietary Manager Essential duties and Responsibilities dated 3/23/17 documents:
Review departmental complaints and grievances from personnel and make written reports to the Dietician
and/or Administrator of action(s) taken.
On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45,
R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group
meetings.
All six residents stated food served at mealtimes is not hot when served, meals were not served on time frequently served 30 minutes to 1 hour late (from the posted mealtimes), they were unaware of the facility
grievance procedure and had requested short activity trips outside of the facility. R10 and R15 stated that
V10, Activity Director, is the staff member who arranges and attends the Resident Council monthly
meetings.
During the group meeting, R15 stated they told V10, Activity Director a couple months ago they would like
to have bus rides/activity trips out of the facility and never heard any response.
R10 stated he has not been out of the facility in two years.
On 6/27/23 at 2:40pm V11, Activity Aide stated she was told by R10, R15 and R38 that they would like to
go on bus rides. V11 stated she reported the resident requests to V10 and the response from V10 was the
bus is busy during the week and there's no one to drive the bus on weekends so there's no way to take
residents for offsite trips.
Five of six residents (R15, R38, R45, R56, R123) stated they were not offered bedtime snacks and didn't
know where they were located or what was available.
Resident Council Meeting Minutes dated 5/25/23 at 2pm indicates Meals are served late, some foods are
hard to eat, and more shade is needed on the patio.
Resident Council Meeting Minutes dated 4/27/23 at 2pm indicates Bread is dry on sandwiches and food
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
145437
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0565
isn't very hot.
Level of Harm - Minimal harm
or potential for actual harm
Resident Council Meeting Minutes dated 1/26/23 at 2pm indicates Old Business: Food not hot
Residents Affected - Some
On 6/28/23 at 12:25pm V12, Dietary Manager stated she did not recall being told about any of the Resident
Council group concerns by V10, Activity Director and she should be told if there are any dietary/kitchen
concerns.
On 6/29/23 at 11:45am V10 stated I just verbally tell the resident group concerns to the staff. I don't
document the response or interventions. V10 stated she was aware the residents had requested bus trips I
just need to reserve the van calendar a month in advance if we want to use the bus for activity trips. V10
could not provide a reason why she had not been scheduling the activity van trips.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on observation, interview, and record review the facility failed to ensure all residents were informed
regarding the facility Grievance process. This failure has the potential to affect all 66 residents who reside in
the facility.
Findings include:
Facility Policy/Grievances dated/revised 9/25/17 documents: The resident has the right to voice grievances
to this facility or other agency or entity that hears grievances.
An Appointed Grievance Official is responsible for overseeing the grievance process.
Resident Census and Conditions Report dated 6/27/23 indicates 66 residents in the facility on that date.
On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45,
R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group
meetings.
All six residents stated they were unaware of the facility grievance procedure.
R10 and R15 stated that V10, Activity Director, is the staff member who arranges and attends the Resident
Council monthly meetings.
On 6/29/23 at 11:40am V5, SSD (Social Service Director) stated she was the Grievance official and was
unsure how the residents get information about the grievance process other than when they are told during
admission. V5 stated she was also unaware of any posted Grievance procedure.
No posted Grievance process/procedure was found throughout the facility and was confirmed as not posted
by V1, Administrator on 6/29/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to revise resident care plans for two of 20 residents (R19 and
R59) reviewed for care plans in the sample of 33.
Findings include:
The facility's Comprehensive Care Plan Policy, revised 11/17/17, states, Purpose: To develop a
comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and
services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and
psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive
person-centered care plan for each resident, consistent with the resident's rights, that includes measurable
objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that
are identified in the comprehensive assessment. This same policy documents that comprehensive care
plans must be reviewed and revised by the interdisciplinary team after each assessment.
The facility's Fall/Incident Occurrence-Assessment and Documentation Guidelines, revised 1/4/16,
documents after a resident fall, preventative measures are to be implemented and the resident's service
plan is to be updated as indicated.
The facility's Fall Prevention Program, revised 11/21/17, documents that resident Care Plans incorporate
the following: each resident fall; interventions changed with each fall and preventative measures.
1. R19's Witnessed Fall Report, dated 4/13/23, states, (R19) was ambulating with therapy and fell. (R19)
was sent out to the ER (Emergency Room) for an evaluation for a hematoma to the right side of her
forehead and returned to the facility. Root cause is weakness. Discussed with IDT (Interdisciplinary Team)
and the intervention is to allow (R19) to sit down in the wheelchair when she needs to rest. Plan of care
reviewed and updated.
R19's current Care Plan documents R19 is at risk for falls and that R19 had an actual fall on 4/13/23.
As of 6/27/23, R19's current Care Plan did not document a new fall prevention intervention after R19's
4/13/23 fall.
2. R19's current Face sheet documents R19 with a diagnosis of Schizoaffective Disorder.
R19's current Care Plan states, I use antipsychotic medications r/t (related to) Schizophrenia with an
initiation date of 3/2/21.
R19's Discontinue Order sheet documents an order for Olanzapine (Antipsychotic) 2.5 milligram tablet at
bedtime related to Schizoaffective Disorder to be discontinued on 11/25/22. This same sheet documents
the Olanzapine order was discontinued related to a Gradual Dose Reduction/GDR.
R19's Psychiatry Note, dated 5/26/23, documents R19's Olanzapine medication was discontinued on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
11/25/22.
Level of Harm - Minimal harm
or potential for actual harm
As of 6/30/23, R19's current Physician Order Sheet did not document any orders for an Antipsychotic
Medication.
Residents Affected - Few
On 6/29/23 at 11:56 AM, V1 (Administrator) verified that R19 is not currently on any antipsychotic
medications and verified that R19's 4/13/23 fall intervention was not added to R19's Care Plan prior to
6/28/23 and should have been.
On 6/29/23 at 1:10 PM, V3 (Assistant Director of Nursing) stated that R19's antipsychotic medication was
discontinued on 11/25/22. V3 stated the medication should have been removed from R19's Care Plan but
was not.
3. R59's current Care Plan documents I am a smoker.
R59's current Smoking Safety Risk Assessment, dated 3/29/23, documents that R59 was admitted to the
facility on [DATE] and that R59 does not currently smoke.
During the survey dates of 6/27/23 through 6/29/23, R59 was not observed smoking during the Facility
Smoking Breaks.
On 6/29/23 at 9:13 am, V1 (Administrator/ADM) stated, (R59) has not smoked since he has been here. He
cannot even get out of bed on his own, let alone smoke, and he is now on Hospice.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the Facility failed to perform hand hygiene and follow a
Physician order during skin care for one (R26) of three Residents reviewed for skin care in a sample of 33.
Residents Affected - Few
Findings include:
Facility Dressing Change/Clean/Non-Sterile Policy, revised 1/9/18, documents: 10. remove soiled dressing
and place in plastic trash bag; 11. remove soiled gloves and place in plastic trash bag; 12. wash hands, or if
hand are not visibly soiled, alcohol based hand gel may be used to decontaminate the hands; 13. apply
clean gloves; 16. apply prescribed ointment and/or dressing per doctor order; and secure dressing in place
if needed.
R26's Wound Physician's Evaluation & Management Summary, dated 6/28/23, documents a Venous Wound
on R26's Right Shin (lower leg). The wound size is 5.5 centimeter/cm by 5.0 cm by 0.1 cm, with a surface
area of 27.5 cm, with moderate serous exudate/drainage. R26's treatment order documents on order for
medicated ointments (Leptospermum Honey and Alginate Calcium) and a Dry Dressing (Gauze Island with
border) to be applied once daily for 30 days.
On 6/28/23, at 11:49am, V7 (Registered Nurse) applied gloves, without hand hygiene, removed R26's
soiled dressing and applied the medicated ointments (Leptospermum Honey and Alginate Calcium) to
R26's Right Shin). V7 then proceeded to apply the Dry Dressing (Gauze Island with border) as V7 was
disposing of the new dressing wrappers into the trash receptacle, V7's writing instrument (Magic Marker)
fell into the trash receptacle. V7 then picked the writing instrument out of the trash receptacle and put it into
V7's clothing pocket, then proceeded to apply the clean dressing. The Dry Dressing was not adhered and
did not cover the entire venous wound and the medicated gauze dressing was exposed and not fully
covered. V7 did not perform hand hygiene prior to applying gloves for the dressing change or change
gloves after removing the contaminated soiled dressing.
On 6/28/23, at 11:55am, V7 (Registered Nurse) stated, I am sorry, I just get so nervous, I should have
changed my gloves and washed my hands. I should not have picked that marker up out of the trash can
either.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0801
Level of Harm - Minimal harm
or potential for actual harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on observation, interview, and record review the Facility failed to staff a Certified Dietary Manager.
This failure has the potential to affect all 66 Residents residing in the Facility.
Residents Affected - Many
Findings include:
Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility.
Facility Position Title (Dietary Manager), created 3/23/17, documents: the Dietary Manager is responsible
for partnering with the Dietician to plan, organize, develop, and direct the overall operation of the Dietary
Department in accordance with current Federal, State and Local standards, guidelines and regulations
governing our facility; review the departments procedure manuals and job descriptions, at least annually;
and must possess a Food Service Sanitation Manager Certification.
V12's (Dietary Manager) Certificate of Completion for Food Service Sanitation Manager Certification, dated
1/8/22, documents that V12 completed the online training. The Certificate of Completion also documents
that This is not the Food Service Sanitation Manager Certificate. V12 stated your Food Manager Exam
must be scheduled separately, and your official certificate will be issued by the Illinois Department of Public
Health or the Chicago Department of Public Health upon passing the exam.
On 6/29/23 at 11:28am, V12 stated, I took the Food Service course over a year ago, but I never took the
exam. I am not sure why I did not take the exam.
On 6/29/23, at 1:00pm, V1 (Administrator) reviewed V12's Certificate of Completion for Food Service
Sanitation Manager Certification, dated 1/8/22, and stated, I never noticed that (V12) did not take the Food
Manager Exam.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0809
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and
requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to
eat at non-traditional times or outside of scheduled meal times.
2) Facility Policy/Snacks and House Supplements: House snacks provide additional calories and meet a
resident's individualized nutritional and care plan needs.
HS (bedtime) snacks should provide a minimum of a starch or bread serving and fruit drink.
On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45,
R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group
meetings.
Four residents (R15, R38, R45, R56) stated they were unaware there were bedtime snacks available, did
not know what snacks were supposed to be provided and were not offered bedtime snacks at any time in
the evening. R10 stated sometimes staff offered snacks at night, but not always.
On 6/28/23 at 12:25pm V12, Dietary Manager stated bowls of graham crackers and other crackers are
placed at the nurse's station every night usually between 7 and 7:30pm. V12 stated she doesn't know what
happens to them after the bowls are at the nurses station. V12 stated They should be offered to the
residents.'
Based on observation, interview, and record review the facility failed to serve meals at the scheduled
mealtime. This failure has the potential to affect all 66 Residents residing in the facility. The facility also
failed to provide bedtime snacks for five residents (R10, R15, R38, R45, R56) of six residents reviewed for
bedtime snacks in the sample of 33.
Findings include:
Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility.
Facility Mealtimes, undated, documents Facility meal times of 7:00 am, 11:00 am and 5:00 pm.
Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot.
Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot.
Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late.
On 6/28/23, at 11:00am through 11:29am, all residents in the [NAME] Side dining room did not have a meal
tray. The Facility meal cart was delivered on 6/28/23 at 11:29am and passing of the meal trays began at
11:30am.
On 6/29/23, at 11:00am through 11:28am, all residents in the East Dining Room did not have a meal tray.
On 6/29/23, at 11:00am through 11:41am, all Residents in the [NAME] Dining Room did not have a meal
tray. The East Dining Room meal cart was delivered to the East Dining Room at 11:28am and the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0809
[NAME] Hall Dining Room meal cart was delivered at 11:41am.
Level of Harm - Minimal harm
or potential for actual harm
On 6/28/23, at 10:00am, during the Resident Council Meeting, R10, R15, R28, R45, R56 and R123 verified
that mealtimes are not served as posted and that meals are served a half-hour to an hour late, also making
the food cold.
Residents Affected - Many
On 6/28/23, at 12:18pm, V12 (Dietary Manager) stated, We do not start serving the main dining rooms until
after we serve our Dementia Unit. Our scheduled lunch mealtime is 11:00 am, but we do not usually get the
carts out until close to 11:30 am.
On 6/29/23, at 11:50am, V12 (Dietary Manager) stated, I had a staffing issue today, so that is why the lunch
meal was late.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Princeton
515 Bureau Valley Parkway
Princeton, IL 61356
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review the facility failed to maintain required safe
serving/holding food temperatures for Resident meals. This failure has the potential to affect all 66
Residents residing in the facility.
Findings include:
Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility.
Facility Serving Temperatures for Hot and Cold Foods Policy, dated 2020, documents: food will be served at
the following temperatures to ensure a safe and appetizing dining experience; and required meat and
vegetable temperatures of 135 degrees Fahrenheit to 170 degrees Fahrenheit.
Facility Mealtimes, undated, documents Facility mealtimes of 7:00am, 11:00am and 5:00pm.
Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot.
Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot.
Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late.
On 6/27/23, at 11:40am, the meatloaf temperature was 102 degrees (Fahrenheit) and the sliced carrots
were 120 degrees (Fahrenheit).
On 6/28/23, at 10:00am, during the Resident Council Meeting, R10, R15, R28, R45, R56 and R123 verified
that mealtimes are not served as posted and that meals are served a half-hour to an hour late and are
often cold.
On 6/28/23, at 12:18pm, V12 (Dietary Manager) stated, I do not know why the meatloaf and carrots were
that cold, I did not even notice the low temperature. I know we have had prior complaints about the cold
food temperature.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 10 of 10
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the June 29, 2023 survey of GOLDWATER CARE PRINCETON?
This was a inspection survey of GOLDWATER CARE PRINCETON on June 29, 2023. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GOLDWATER CARE PRINCETON on June 29, 2023?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.