Health inspection·December 26, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide showers/bathing assistance for two of six residents (R8, R9) reviewed for showers in the sample list of 11 residents. Residents Affected - Few Findings include: The Bathing-Shower and Tub Bath policy revised 1/31/18 documents a shower, tub bath or bed/sponge bath will be offered according to resident preference two times per week or as needed or requested. The 10/1/24 Resident Council Meeting Minutes document residents are not consistently getting showers or teeth brushed. The 11/1/24 Resident Council Meeting Minutes document residents are having to ask for showers. On 12/26/24 at 6:53 AM, R8 stated last week I never got my shower, and I'm not sure why. R8 stated R8 asked about a shower, but never received one. R8 stated R8's normal shower days are Monday, Wednesday and Friday. R8 stated R8 does not always receive R8's showers. On 12/24/24 at 8:00 AM, R9 stated he has not received a shower since he was admitted to the facility. R9 stated he has asked staff for some wet wipes so R9 can clean himself in his room and the staff stated they did not have them anymore. R9 stated R9 has been at the facility about three weeks. R9 further stated he has not received a sponge bath or shower from the staff. R9's hair appeared greasy and R9 had an odor. R9's electronic medical record documents R9 was admitted to the facility on [DATE]. R9's Minimum Data Set, dated [DATE] documents R9 is cognitively intact. On 12/26/24 at 6:57 AM, V16 Certified Nursing Assistant (CNA) stated a lot of residents have dementia and behaviors and we don't have enough aides on the floor to care for them and showers don't get completed sometimes. V16 stated once we give a shower and come out of shower room all the call lights are on and many residents are fall risks, so we do daily showers, but not all of them get done. On 12/26/24 at 6:15 AM, V5 Registered Nurse stated she does not feel the showers are being done consistently. V5 stated the CNAs get weekly shower sheets and that's how they know who needs showers. V5 stated for a while those were not being updated when new residents admitted to the facility and showers were being missed. On 12/26/24 at 8:00 AM, V2 Director of Nursing stated she did not have shower sheets for R8 or R9. Page 1 of 3 145016 145016 12/26/2024 Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to have an operational Legionella water management plan. This failure has the potential to affect all 72 residents residing in the facility. Residents Affected - Many Findings include: The Water Management Program for Prevention of Legionella Growth documents that this procedure policy was last reviewed on 6/27/23. This policy documents additional monitoring or action may need implemented for the following risk factors, hot water temperature dropping where Legionella can grow, areas in pipes with stagnation. In areas where water is not used or is off the facility will do routine flushing of water lines (i.e. Running water for 15 minutes weekly in sinks or showers not in use, etc.). The Facility Assessment last reviewed 12/2024, does not contain a procedure to conduct a facility risk assessment to identify potential Legionella growth and other waterborne pathogens in the facility water system or specific testing protocols and acceptable ranges for control measures. On 12/26/24 at 5:30 AM, V15 Maintenance Director stated the out of order room which has a zipper wall in front of the door has been closed for a few months after finding water leakage on the wall in the room that adjoins to the shower room which is also closed. V15 stated water from the shower room was seeping thru the wall into the adjoining room. V15 stated after seeing water damage on wall V15 closed the room and the shower room and removed the wall adjoining the rooms. V15 stated it's an old building and the tiling between the rooms was broken. V15 stated they did find mold in the wall which they removed. V15 stated no one has tested the water in the facility in the two years he has worked here for Legionella. V15 stated the facility runs water in the rooms that are out of order for 10 minutes once a month. V15 stated he has never been told the water needed tested. On 12/24/24 at 12:45 PM, V1 Administrator stated V15 is responsible for overseeing the facilities Water Management Plan and any testing of water that needs done. The Daily Census sheet dated 12/23/24 documents 72 residents residing in the facility. 145016 Page 2 of 3 145016 12/26/2024 Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review the facility failed to ensure water temperatures were at comfortable levels. This failure has the potential to affect all 72 residents in the facility. Residents Affected - Many Findings include: The Shower and Tub policy last revised 1/31/18 documents for staff to turn on water and ensure that water is a comfortable and safe temperature. Temperature should be 100-110 degrees Fahrenheit. The Room Water Temperature log dated 11/22/24 through 12/23/24 documents resident room temperatures are obtained twice weekly in Main Room, East Room, Main Building Temperature and East Building Temperature. The Resident Council Meeting Minutes for 7/2/24 document a concern with no hot water in the beauty shop and the showers are getting cold. The Maintenance Department documents that the water tank is still being reviewed to be replaced. Resident Council Meeting Minutes dated 9/5/24 document the temperature of the water on the west side of the building is colder than normal. The Maintenance Department documents they will turn off shower room water when not in use, so it does not draw all the hot water. 12/24/24 at 8:15 AM, V15 Maintenance Director obtained random water temperature readings in resident rooms and shower rooms. One room was 74 degrees Fahrenheit after four minutes of hot water running, and one room was 99 degrees Fahrenheit after several minutes of hot water running. V15 stated he was going to the check boilers in the basement. V15 stated the water temperatures in resident rooms should not be this low. V15 stated the water temperature should be between 100 degrees Fahrenheit and 110 degrees Fahrenheit. On 12/24/24 at 8:30 AM, V15 stated he checks water temperatures twice a week on Monday and Friday. V15 stated he checks one room on each side of the building. V15 stated it could be possible other rooms have different temperatures depending on their location. The Daily Census sheet dated 12/23/24 documents 72 residents residing in the facility. 145016 Page 3 of 3