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
record review and interview the facility failed to conduct a quarterly care plan meeting since admission for
one of 6 (R1) residents reviewed for care plans in a sample of 6.
Findings Include:
The facility policy named, Comprehensive care plan, dated 11/17/2017, documents, The resident and/or
resident representative shall be invited to review the plan of care with the interdisciplinary team either in
person, via telephone, or video conference (if available) at least quarterly.
R1's Nurses Notes, documents R1 was admitted on [DATE].
R1's Minimum Data Set progress note, dated 5/19/2023, documents, R1's invite to a care plan meeting.
On 10/13/2023 at 2:20PM V6/Care Plan Coordinator stated, I have been in this role since March of this
year. I did invite V9/R1's daughter to the care plan meeting for R1 on 5/19/2023 for the yearly review. I did
not send out an invite for R1's quarterly review in August. I do not know why I did not send a care plan invite
for August to have the quarterly care plan prior to March of this year, I could not find any records to show
care plans were being done and R1 and family was invited.
On 10/13/2023 at 11:45AM V1/Administrator stated, There was Covid-19 in the facility last year, that could
be one reason R1's care plans were not done. V6/Care plan Coordinator could not find any other
documents besides the 6/18/2022 invite and the 5/19/2023 invite to show R1 had the quarterly care plans.
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
10/13/2023
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to administer medications safely for one of three
residents reviewed (R3), in a sample of six. This failure resulted in R3 ingesting R2's medications.
Residents Affected - Few
FINDINGS INCLUDE:
The undated facility policy, Medication Administration General Guidelines, directs staff, medications are
administered as prescribed in accordance with good nursing principles and practices and only by persons
legally authorized to do so. Five Rights- Right resident, right drug, right dose, right route, and right time, are
applied for each medication being administered. When medications are administered by mobile cart taken
to the resident's location (room, dining area, etc ) medications are administered at the time they are
prepared. Medications are not pre-poured either in advance of the med (medication) pass or for more than
one resident.
R2's current Physician Order Sheet, dated October 2023 includes the following medications: Aspirin (blood
thinner) 81 MG (milligrams) one tablet in the morning; Clopidogrel (antiplatelet)75 MG one tablet in the
morning; Ergocalciferol (dietary supplement) 50000 Units one capsule in the morning; Furosemide (diuretic)
40 MG one tablet in the morning; Iron (dietary supplement) 325 MG one tablet in the morning; Isosorbide
Monoltrate ER (extended release) (nitrate) 30 MG one tablet in the morning; Jardiance (sodium-glucose
co-transporter) 10 MG one tablet in the morning; Pantoprazole (proton pump inhibitor) 40 MG one tablet in
the morning; Vitamin D2 (supplement) 50 MCG (micrograms) one tablet in the morning; Carvedilol (beta
blocker) 12.5 MG one tablet twice daily; Eliquis (Factor Xa inhibitor) 5 MG one tablet in the morning;
Metformin (oral anti-diabetic) 1000 MG one tablet twice daily.
On 10/13/23 at 8:10 A.M., R2 was sitting in bed, writing a note. R3 was seated in a wheelchair, next to R2's
bed. R2 and R3 were alert, oriented and talkative. R2 and R3 were able to recall the incident of 10/5/23. At
that time, R2 stated, It was approximately 8:00 AM, when the nurse (V4/RN) placed two small plastic
medication cups, both full of pills, on the table in front of us (R2 and R3). (R3) reached over, grabbed a
medication cup and swallowed the pills. When I went to swallow my pills, I realized (R3)'s name was on the
cup and refused to take the medications. V4/RN was standing at the table during this time but didn't stop
(R3) from taking (my) pills.
On 10/13/23 at 9:51 A.M., V4/Registered Nurse stated, I was working the morning of 10/5/23. It was about
8:00 A.M. (R2) and (R3) were seated at the same dining room table, eating their breakfast. I had put all of
(R2)'s medications and (R3)'s medications in separate, small, plastic med (medication) cups, took them to
their table and set them down. As I was placing cups of water on the table, (R3) reached over and took
(R2)'s medications. I called (R3)'s doctor and he told me to hold (R3)'s blood pressure medications and
monitor (R3)'s blood pressure hourly. I shouldn't have tried to give (R2 and R3) medicine at the same time.
The (facility) Medication Error Form, completed by V4/Registered Nurse, dated 10/5/23 documents,
Incident occurring on 10/5/23 at 8:00 A.M. (R3) at dining room table and (R2)'s meds (medications) were
sat down. While (V4/RN) was sitting down water and arranging things, (R3) grabbed meds (medications)
and took them. (R3)'s MD (Medical Doctor) notified and (R3)'s blood pressure pills held. (Physician order) to
monitor blood pressure hourly. (R3) is alert and oriented to person, place, time and situation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145437
If continuation sheet
Page 2 of 2
