Inspection·September 20, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate an allegation of a potential misappropriation of resident property for one (R9) of three residents reviewed for criminal activity in a sample of three. Residents Affected - Few Findings include: The facility's Abuse Prevention and Reporting - Illinois policy, revised 10/24/22, documents Internal Reporting Requirements and Identification of Allegations: Supervisors shall immediately inform the administrator of person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. R9's current clinical record, documents R9 as moderately cognitively impaired with diagnoses including Unspecified Dementia, moderate, with Agitation. R9's Criminal History Record, dated 1/16/23, documents R9 is a Registered Identified Sex Offender and was convicted for indecent liberty of a child in 1979 and 1980. On 9/19/23, at 12:03pm, R9 was lying in bed with a personal computer located on a desk against the wall across from the entrance to R9's room. At this time R9 stated he does use the WIFI for Internet on his personal computer and that there's porn on there, but you don't have to stay on it. You can skip on by it, ya know? On 9/19/23, at 2:27pm, V1 stated the following: A nurse (V9 Registered Nurse/RN) called me a week ago and said (V21 Certified Nursing Assistant/CNA) reported to (V9) that (V21) suspected (R9) was on a porn site. I asked (V9) if she saw it and (V9) did not. I did not talk to (V21 CNA). At this time, V1 denied doing any investigation for this allegation and was unable to provide any investigation documents. On 9/19/23, at 2:57pm, V21 CNA, stated that V21 walked into R9's room where loud music was playing and saw R9 on his computer viewing young Chinese girls aged 10 to [AGE] years old whose dresses were blowing up exposing their underwear. Each time they put a microphone up to their mouths their dress would fly up. What got me was the phone numbers going across the back. V21 stated she reported this to V9 Registered Nurse/RN but is not sure if anything was done. V21 stated that no one from the facility has asked her anything about this occurrence. (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 5 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 09/20/2023 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)