Complaint Investigation

Goldwater Care Bloomington

August 17, 2025 · Bloomington, IL · 700 East Walnut

Citations 1

CMS Rating 1/5

Beds 88

Provider ID 145016

Healthcare Facility

Goldwater Care Bloomington

Bloomington, IL · View full profile →

Inspection Summary

GOLDWATER CARE BLOOMINGTON in BLOOMINGTON, IL — inspection on August 17, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689

Quality of Life and Care Deficiencies

Actual Harm

1:50 PM V13 Certified Nurse Aide (CNA) stated staff have to get R1 set up just like R1 wants or R1 won't be able to manage eating by herself. On 8/16/25 at 2:45 PM V15 Certified Nurse Aide (CNA) stated V14 CNA served R1 her breakfast tray on 8/4/25. V15 CNA stated R1 ended up spilling her hot coffee on her Left Hip. V15 CNA stated he heard R1's call light sounding but not sure how long. V15 CNA stated the staff are all very busy at that time of morning trying to get everyone ready for breakfast. V15 CNA stated R1 needs set up assistance with her meals but 'the staff never stay in the room' with R1. On 8/16/25 at 3:00 PM V1 Administrator stated R1's Minimum Data Set (MDS) assessment does not match R1's care plan and R1's Kardex. V1 Administrator confirmed R1's Electronic Medical Record (EMR) does not include any documented refusals from R1 of staff being present for meals to assist R1 if necessary. V1 Administrator stated the facility does not have a policy on serving hot liquids to cognitively impaired residents. On 8/16/25 at 3:40 PM V2 Director of Nurses (DON) stated staff should follow the MDS and care plan. V2 DON confirmed R1's MDS, care plan and Kardex do not match which could be confusing for staff. V2 DON stated R1 should have been assisted with setting up her tray so that she could manage the drinks which would have prevented her from being burned. V2 DON stated the staff were in-serviced due to R1 being burned and will also in-service the staff on documenting refusals of care.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BLOOMINGTON, IL, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GOLDWATER CARE BLOOMINGTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

Goldwater Care Bloomington

Inspection Findings

Frequently Asked Questions

More Reports