Health inspection·August 24, 2023

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure resident trust funds were accurate, monies due to residents were credited in a timely manner, and safeguards were in place for managing resident funds for two residents (R3 and R4) of six residents reviewed for resident trust funds in a sample of six. Residents Affected - Few Findings include: The facility's Resident Funds policy, revised 4-29-19, documents Guidelines: This facility manages the personal funds of residents when such request is made by the resident. Resident funds may be managed by any of the following: d. The resident may choose to have the facility hold, safeguard, and manage his/her personal funds. This policy also states 4. Resident funds are deposited into an interest-bearing resident trust fund account which is different from the facility's banking account. And 6. Inquiries concerning the facilities management of resident funds should be referred to the administrator or the business office. 1. R3's Minimum Data Set/MDS assessment, dated 6-4-23, documents R3 is cognitively intact. On 8-23-23, at 11:15am R3 is lying in bed watching television. R3 confirmed that the facility manages R3's funds and R3's stay here is paid out of R3's Social Security money. R3 continued to state the following: Sometime last year $600 was taken from R3's account and never replaced. R3 stated that R3 spoke to the finance person many times about it. R3 was told it was for rent, but rent was already paid. R3 received letters from R3's bank saying R3 was overdrawn. R3 stated I never got any answers or the money back. R3's resident trust fund statements, dated 8-23-23, document that R3's room and board was paid for twice in September 2022. On 9-2-22 there was a Care cost automatic withdrawal for $609.64. On 9-8-22 there was a bank debit of $609.64 into R3's trust fund followed by a payment in the same amount made for R3's room and board. This same statement documents that $609.64 was refunded to R3's trust fund on 10-25-22. R3's resident trust fund statements, dated 8-23-23, document that R3's room and board was paid for twice in May 2023. On 5-3-23 there was a Care cost automatic withdrawal for $682.64. On 5-15-23 there was a bank debit of $682.64 into R3's trust fund followed by a payment in the same amount made for R3's room and board. On 5-19-23 R3 incurred a $53.00 fee for lack of funds. These same statements do not document any refund of $682.64 or $53 for the fee. On 8-23-23, at 1:15pm, V2 Regional Financial Coordinator stated the following: On 9-8-22 there was an auto withdrawal of $609.64 for R3's room and board. On 9-8-22 an auto payment of $609.64 was (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 2 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 08/24/2023 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)