Goldwater Care Bloomington: Hot Coffee Burn Violation - IL
The resident, identified in inspection records only as R1, required staff to set up her meals in a specific way so she could eat independently. A CNA told inspectors that staff "never stay in the room" with R1 during meals, despite her documented need for setup assistance. The same aide said he heard her call light sounding after the burn but wasn't sure how long it had been going off. It was a busy morning, he said. Everyone was trying to get residents ready for breakfast.
The burn was not a surprise waiting to happen. It was a known risk that staff had simply stopped managing.
When inspectors arrived on August 16, the facility's administrator acknowledged that R1's Minimum Data Set assessment, her care plan, and her Kardex, the quick-reference document staff use at bedside, did not match each other. Three separate documents meant to tell staff how to care for this woman were giving different information. The administrator also confirmed that R1's electronic medical record contained no documented refusals of staff assistance during meals, meaning there was no record suggesting she had ever turned help away.
Then came the detail that stands apart from the paperwork failures. The administrator told inspectors the facility had no policy on serving hot liquids to cognitively impaired residents.
None.
The Director of Nurses confirmed the mismatch between the MDS, care plan, and Kardex, and said the inconsistency "could be confusing for staff." She said R1 should have had help setting up her tray so she could manage her drinks, and that the help would have prevented the burn. After the injury, staff were given in-service training. More training was planned on documenting when residents refuse care.
The inspection was conducted as a complaint investigation and resulted in a citation at the "actual harm" level, the federal designation used when a violation causes real injury to a resident, not merely the risk of one.
What the records show is a resident whose needs were documented in at least three places, none of which agreed with the others, and a staff culture in which leaving a cognitively impaired woman alone with a hot beverage had become routine. The CNA who described it didn't frame it as a lapse. He described it as how things worked. The staff are busy in the mornings. They don't stay in the room.
The Director of Nurses said staff should follow the MDS and the care plan. But when those documents contradict each other, and when no one has written a policy covering hot liquids and cognitive impairment, what staff follow in practice is whatever they have time for.
R1 needed her tray set up a particular way. She needed someone to stay. On August 4, neither happened, and she burned herself on coffee that should never have been placed within her reach without assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Bloomington from 2025-08-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 18, 2026 · Our methodology
GOLDWATER CARE BLOOMINGTON in BLOOMINGTON, IL was cited for violations during a health inspection on August 17, 2025.
The resident, identified in inspection records only as R1, required staff to set up her meals in a specific way so she could eat independently.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.