Inspection·July 28, 2025

F 0684 Level of Harm - Actual harm and R4 was giving goofy answers to her questions and kept saying that her daughter was at the facility. V2 stated that V11 should have got a set of vital signs on V11 and should have notified V12 when R4's condition worsened. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145016 If continuation sheet Page 2 of 9 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 145016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent a fall by failing to ensure fall precautions were in place and failed to minimize the risk of injury from a fall by failing to ensure interventions to reduce the risk of injury were in place. The facility also failed to ensure fall precautions and interventions were in place after a fall with injury for one (R1) of three residents reviewed for falls on the sample list of four. This immediate jeopardy began on [DATE] at 8:00 PM when this failure resulted in R1 having a high impact fall on [DATE] from an elevated bed onto the floor. This fall resulted in R1 sustaining a right leg fracture with shattered and displaced bone fragments. This fall contributed to R1's death five days later [DATE]. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 10:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's undated Care Plan documents diagnoses including cerebral infarction, cerebral aneurysm, thrombocytopenia, dysarthria and anarthria, rheumatoid arthritis, type II diabetes mellitus with diabetic neuropathy, and pain in right knee. This care plan documents R1 requires maximum assistance of two people for bed mobility and sitting up and R1 requires a mechanical lift for transfers. R1's Fall Care Plan dated 3/2024 documents R1 has a history of falls and contains an intervention dated [DATE] to have fall mats on the floor next to the bed and for the bed to be in the low position when R1 is in bed due to the history of R1 rolling out of the bed onto the floor. This care plan documents R1 has fallen out of bed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].On [DATE] at 10:08 AM, R1 was lying in bed on a low air loss mattress. R1's bed was elevated three feet from the floor. Fall mats were not lying on the floor beside the bed. At this time R1 was unresponsive. R1 was breathing with mouth open, and breaths were irregular and labored. On [DATE] at 9:25 AM V31, Maintenance Director measured the height of R1's bed frame from the floor in standard position at 22 inches, then measured the bedframe from the floor at the position R1's bed was observed to be (on [DATE]) when R1 was in bed. This bed position measured 32 inches from floor. V31 stated the air mattress was at minimum 4 inches in height which would put R1 36 inches from floor when observed lying in bed. V31 verified this is a high position for bed. The Progress Note by V8 Registered Nurse (RN) dated [DATE] documents on [DATE] at 8:00 PM R1 was found on the floor next to the bed on his back after V13, Certified Nursing Assistant (CNA) heard his screams from another resident room. V8, documents that R1 fell from the bed in the high position with the low air loss mattress on and inflated. R1 complained of right knee pain and required four staff assist including the mechanical lift to transfer R1 to the bed. V8 documents R1's POA (V30) and hospice physician (V25) were notified, and orders were received to keep R1 comfortable with morphine and to not send R1 to the hospital at that time.The Incident Statement dated [DATE] documents, V13 CNA stated she was in another resident room when she could hear R1 screaming. R1's Progress Note dated [DATE] at 8:15 PM documents V32, LPN, contacted hospice staff stating R1 was having continued uncontrolled right knee pain after pain medication was administered as ordered, and staff cannot reposition R1 without extreme pain.R1's Physician Orders dated [DATE] document a new order for a 2-view x-ray of R1's right knee related to pain in the right knee and a one-time administration of 20mg of Morphine to be given for uncontrolled pain. At 3:07 PM on [DATE] V30, R1's Family Member stated she came to see R1 on Monday [DATE]. V30 stated she was notified of the fall on [DATE] around 9:00 or 9:30 PM. V30 stated she had not been in to see R1 all weekend but had called for updates on [DATE] and [DATE] and was told that R1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145016 If continuation sheet Page 3 of 9 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 145016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was just a little sore and bruised. V30 stated when she entered R1's room on [DATE] R1 was receiving a sponge bath from a CNA (unnamed). V30 stated R1 was not being moved but screaming in pain just from touch alone. R1's Biotech X-Ray report dated [DATE] at 11:22 AM documents R1 has an acute comminuted fracture distal femur with 3cm dorsal lateral displacement distal fragments noted. R1's progress notes dated [DATE] document R1 was sent to the local emergency department per family request. R1's Hospital Records dated [DATE] document R1 reported significant pain to the right hip area upon arrival on [DATE] and R1 had obvious gross deformity to the right lower extremity with significant enlargement of the right thigh. Right leg x-ray was completed at 3:32pm on [DATE] with results of acute comminuted fracture distal femoral Meta diaphysis just above prothesis with distal fragment displaced laterally and posteriorly by 4cm and right hip fracture cannot be ruled out. Records document R1's family declined surgical intervention due to R1's bleeding disorder and complications associated with surgery and that R1 was placed in a knee immobilizer and returned to the facility.R1's Nurse Practitioner Visit Note dated [DATE] documents R1 fell out of bed ([DATE]) Friday night when trying to reach something at the request of his roommate. R1 had significant pain throughout the weekend. X-ray's obtained yesterday ([DATE]) confirmed R1 had an acute comminuted distal femur fracture of the right femur just above the prosthetic. R1 considered high risk for surgery and would have required transfer to different hospital. Family opted for conservative treatment. Added scheduled morphine due to R1's pain level in addition to current as needed ordered morphine. Family wishes to continue to focus on comfort. R1's progress note dated [DATE] at 10:50 AM documents R1 expired at facility. R1's death certificate dated [DATE] documents Immune Thrombocytopenic Purpura with contributing factors of ischemic heart disease and fracture of femur related to fall listed as cause of death. Manner of death listed as accident. On [DATE] at 1:51 PM, V34, Deputy Coroner, stated R1's cause of death was listed as Immune Thrombolytic Purpura (ITP) which is a low platelet count, this contributed to R1 being unable to have surgery to set his fracture. V34 stated this was an extensive traumatic fracture and that it contributed to R1's death with manner of death as an accident. V34 stated the significant pain R1 suffered caused stress to his heart and was also a significant factor attributing to his death. On [DATE] at 12:33 PM, V15 Certified Nurse Assistant (CNA) stated she was working the night R1 fell but was not R1's assigned CNA. V15, CNA stated she was in a resident's room when the fall occurred. V15, CNA stated when she entered R1's room after his fall, R1 was screaming out in pain stating his right knee hurt requesting staff to rub it. V15, CNA stated V13, CNA and V15 were performing care for R1 after his fall and R1 was verbalizing and exhibiting signs of excruciating pain. V15 stated two days later, [DATE], between 8:00 pm and 10:00 pm, V15 and an un-named agency CNA were providing incontinence care for R1 when she felt something move in R1's knee. V15 stated she heard a pop sound, and R1 continued to be in significant pain at this time and she reported both pain and the shifting pop in R1's right leg to V8, RN after care completion. On [DATE] at 2:20 PM, V8 stated R1 was on his back on the floor, no mat, when she was called into the room by R1's cries. V8 stated R1 stated a CNA was just in the room prior to the fall. V8 stated R1 asked staff to stretch his leg out after transferring R1 to bed and that is when R1 screamed out in pain several times. On [DATE] at 10:30 AM, V12 Nurse Practitioner (NP), stated she was not aware of R1's fall on Friday, [DATE]th but was notified the following Tuesday, [DATE]th. V12 stated she found out about the entire event on the morning of 7/15 during the scheduled IDT (Interdisciplinary Team) meeting. V12 stated prior to R1's fall he was stable with minimal intermittent confusion, a pleasant man who she enjoyed caring for. V12 stated that had R1 not fallen he would have lived longer. V12 stated she has never observed fall mats in R1's room. On [DATE] at 2:09 PM, V2 Director of Nursing (DON), confirmed that R1's Care Plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145016 If continuation sheet Page 4 of 9 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 145016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few included an intervention to have fall mats on the floor next to the bed and at the time of the fall he did not have the mats. V2 stated the mat should have been in place to reduce the risk of R1's injury due to his history of rolling out of bed.The facility fall policy dated [DATE] document's the purpose is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions, and to provide necessary supervision, that assistive devices are utilized as necessary. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. On [DATE] V2 Director of Nursing (DON) conducted facility wide audits of all residents' fall care plans. Audits of observations that fall interventions were in place were conducted by Interdisciplinary Team Members (Maintenance Director, Social Services Director, Assistant Director of Nursing, Business Services, and floor RN's)2. On [DATE] V2 DON, V29 Quality Assurance Nurse, and the MDS Coordinator provided education on how to access fall interventions by accessing the resident's Kardex with ongoing education to be provided to staff members on FMLA (Family Medical Leave of Act), vacation, or agency staff.3. On [DATE] V37 [NAME] President of Operations provided education to V1 and V2 regarding the facility's Fall Prevention Program policy that included the DON's responsibilities related to monitoring of the fall prevention program.4. On [DATE] V1 and V2 provided education on the facility's Fall Prevention Program policy to all licensed and certified nursing staff. Ongoing education to be provided to staff members on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.5. On [DATE] V2 and V29 Quality Assurance (QA) Nurse educated Hospice Company staff on the facility's Fall Prevention Program policy.6. On [DATE] V2 and V29 QA Nurse educated all licensed and certified nursing staff on the facility's Incident Accident policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.7. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Pain Management policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.8. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Pain Assessment policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.9. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Physician-Family Notification Change in Condition policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.10. On [DATE] V2 and V29 educated licensed and certified nursing staff on the facility's Basic Care Plan policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.11. On [DATE] V2 and V29 educated all Interdisciplinary team (IDT) members on the facility's Comprehensive Care Plan policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.12. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Resident Rounds guidelines. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.13. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Hospice Service policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.14. On [DATE] an impromptu QAPI (Quality Assurance Performance Improvement) meeting was held with the medical director and staff IDT members to discuss deficiency and facility action plan.15. Starting on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145016 If continuation sheet Page 5 of 9 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 145016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete [DATE] V2, V29 and designee began audits to ensure all new unwitnessed and witnessed falls and the interventions have been added to the resident's care plan. These audits will be ongoing seven days per week for six weeks. Quality Assurance oversight of these audits will be done by V37. The Audit tool dated week end [DATE] documents first audit completed [DATE].The facility presented an abatement plan to remove the immediacy on [DATE] at 1:28 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned [DATE] at 2:42 PM. The facility presented a revised abatement plan to remove the immediacy on [DATE] at 2:51 PM. The survey team reviewed the abatement plan and was able to accept the plan to remove the immediacy. The abatement plan was approved on [DATE] at 3:16 PM. Event ID: Facility ID: 145016 If continuation sheet Page 6 of 9 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 145016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct a comprehensive pain assessment after a fall with injury, failed to administer as needed pain medications as ordered by the physician when signs of symptoms of excruciating pain were present, and failed to notify the family and physician when a change in the level of pain was identified for one (R1) of three residents reviewed for pain on a sample size of four. This failure resulted in R1 suffering excruciating pain in which R1 was observed with facial grimacing, yelling and screaming for four days after sustaining a right leg fracture.R1's Progress Note dated [DATE] documents that on [DATE] at 8:00 p.m., R1 was found on floor next to bed on his back after V13, Certified Nursing Assistant (CNA) heard his screams while V13 was in another resident room. V8, Licensed Practical Nurse (LPN), documents that R1 fell from bed in high position with low air loss mattress on and inflated. R1 complained of right knee pain at 7/10 with no previous complaints of pain and required 4 staff assist including mechanical lift to place R1 back in bed. V8 documents V30, R1's family member, and hospice physician were notified, and facility was to keep R1 comfortable with morphine.R1's undated Care Plan documents diagnosis including cerebral infarction, cerebral aneurysm, thrombocytopenia, dysarthria and anarthria, rheumatoid arthritis, type 2 diabetes mellitus with diabetic neuropathy, and pain in right knee. This care plan also documents R1 has a potential for pain and is on pain medication therapy related to terminal diagnosis on hospice care with a start date of [DATE]; goals listed to have any complaint of pain controlled at acceptable level and to be free of discomfort. Interventions include to administer medications as ordered, assess for pain, and to notify physician if pain medication is non-effective.R1's Hospice Care Plan dated [DATE] documents R1 will be pain free or pain will be at tolerable level.R1's Medication Administration Record (MAR) dated [DATE] documents the following orders for Morphine Sulfate (Concentrate) Solution 20 milligrams(mg) per milliliter (ml) with a start date of [DATE]. -Give 0.25ml every 2 hours as needed (PRN) for pain rated 1-3 on a scale of 10.-Give 0.5 ml every 2 hours as needed (PRN) for pain rated 4-7 on a scale of 10.-Give 1.0 ml every 2 hours as needed (PRN) for pain rated 8-10 on a scale of 10.R1's MAR also documents scheduled order for 325mg of acetaminophen, 2 tabs three times a day, and every 4 hours as needed for pain, not to exceed 4000mg per day, with a start date of [DATE].V14, Hospice Registered Nurse (HRN), documented in R1's Hospice Progress Note dated [DATE] that V8, LPN called and stated R1 had fallen and was complaining of pain. V8, LPN stated R1 did not have any morphine in stock currently, and that she (V8) had no access to emergency box to pull bottle of morphine in facility stating, I'm new here. V8, LPN reported V30, R1's family member did not want R1 sent to hospital. Documents hospice attempted contact with V30 but was unable to verify V30's requests to not transport to local emergency department (ED). A new prescription for morphine was sent to the backup pharmacy and a hospice visit was scheduled for the next day, [DATE].V14, HRN, documented in R1's Hospice Progress Note dated [DATE] that V8, LPN called a second time stating R1 had now vomited three times. V14, HRN instructed V8, LPN to administer anti-emetic as ordered.R1's incident statement dated [DATE], documented V13 CNA stated she was in another resident's room when she could hear R1 screaming. V13 stated when she arrived to R1's room he was visualized in bed screaming in pain with several staff around.R1's Hospice Visit Notes dated [DATE], documented V14, HRN, stated R1 could be heard moaning in pain from down the hall. V14 documented having to wait for facility nurse V9, LPN to return from lunch break to get pain medications to relieve R1's acute pain. V14 stated she had to demand that R1 have medication for pain control as V9 stated no morphine had been retrieved from facility emergency backup supply box yet.R1's MAR dated [DATE] documented on [DATE] at 11:27 AM, Fifteen- and one-half Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145016 If continuation sheet Page 7 of 9 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 145016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701 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 0697 Level of Harm - Actual harm Residents Affected - Few hours post fall incident, 1st administration of PRN pain medication. R1 received ordered prn dose of 20mg/1ml Morphine indicated for pain score of 8-10 on pain scale with 10 being the worst pain. MAR documents sporadic administration of PRN morphine with continued high levels of reported pain until order for scheduled administration received on [DATE].R1's Progress Note dated [DATE], at 8:15 PM, documented V32, LPN, contacted R1's hospice stating R1 is having continued uncontrolled right knee pain after pain medication administered as ordered, and staff cannot reposition R1 without extreme pain.R1's Physician Orders dated [DATE] document new order for a 2-view x-ray of right knee related to pain in right knee and a one-time administration of 20mg of Morphine to be given for uncontrolled pain.R1's Hospital Records with print date of [DATE] documented R1 reported significant pain to right hip area upon arrival on [DATE]. R1 had obvious gross deformity to right lower extremity with significant enlargement of right thigh. Right leg x-ray was completed at 3:32pm on [DATE] with results of acute comminuted fracture distal femoral Meta diaphysis just above prothesis with distal fragment displaced laterally and posteriorly by 4cm and right hip fracture cannot be ruled out. Records document R1's family declined surgical intervention due to R1's bleeding disorder and complications associated with surgery and that R1 was placed in a knee immobilizer and returned to facility.R1's Progress Notes dated [DATE] at 9:54 PM documented R1 in extreme pain after return from hospital.R1's Progress Notes dated [DATE] at 8:30 AM documented R1 complains of severe pain in right leg with little positioning.R1's Nurse Practitioner Visit Note dated [DATE] documented R1 fell out of bed ([DATE]) Friday night when trying to reach something at the request of his roommate. R1 had significant pain throughout the weekend. Xray's obtained yesterday ([DATE]) confirmed R1 had an acute comminuted distal femur fracture of the right femur just above the prosthetic. R1 considered high risk for surgery and would have required transfer to different hospital. Family opted for conservative treatment. Added scheduled morphine due to R1's pain level in addition to current as needed ordered morphine. Family wishes to continue to focus on comfort.On [DATE] at 10:08 AM, R1 was lying in bed on a low air loss mattress. R1's bed was elevated three feet from the floor. Fall mats were not lying on the floor beside the bed. At this time R1 was unresponsive and appeared to be actively dying. R1 was breathing with mouth open, and breaths were irregular and labored.R1's Progress Note dated [DATE] at 10:50 a.m. documents R1 expired at facility.R1's Death Certificate dated [DATE] documents Immune Thrombocytopenic Purpura with contributing factors of ischemic heart disease and fracture of femur related to fall listed as cause of death. Manner of death listed as accident.On [DATE] at 1:51 PM, V34, Deputy Coroner, stated R1's cause of death was listed as Immune Thrombolytic Purpura (ITP) which is a low platelet count, this contributed to R1 being unable to have surgery to set his fracture. V34 stated this was an extensive traumatic fracture and the pain associated with this type of fracture is severe. V34 stated that the significant pain R1 suffered after his fall could have possibly caused stress to his heart becoming a significant factor attributing to his death. On [DATE] at 12:33 PM, V15 Certified Nurse Assistant (CNA) stated that she was working the night that R1 fell but was not R1's assigned to care for R1. V15, CNA stated she was in a resident's room when the fall occurred. V15, CNA stated when she entered R1's room after his fall, R1 was screaming out in pain stating his right knee hurt requesting staff to rub it. V15, CNA stated V13, CNA and herself were performing care for R1 after his fall and R1 was verbalizing and exhibiting signs of excruciating pain evidenced by facial grimacing and crying out in pain. V15 stated that 2 days later, [DATE], between 8 pm and 10 pm, herself and un-named agency CNA were providing incontinence care for R1, and she felt something move in R1's knee. V15 stated she heard a pop sound, and R1 continued to be in significant pain at this time which she reported both pain and shifting pop in right leg to V8, RN after care completion. At 3:07 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145016 If continuation sheet Page 8 of 9 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 145016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Bloomington 700 East Walnut Bloomington, IL 61701 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 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete PM on [DATE] V30, R1's family member stated she came to see R1 on Monday [DATE]. V30 stated she was notified of fall on [DATE] sometime around 9:00 or 9:30 PM. V30 stated she had not been in to see R1 all weekend but had called for updates on [DATE] and [DATE]. V30 stated both times she was told that R1 was just a little sore and bruised. V30 stated she entered R1's room on [DATE] and observed R1 receiving a sponge bath from a CNA (unnamed). V30 stated R1 was not being moved but screaming in pain just from touch alone.On [DATE] at 10:30 AM, V12 Nurse Practitioner (NP), stated that she wasn't aware of R1's fall that he had on Friday, [DATE]th but was notified the following Tuesday, [DATE]th. V12 stated that she found out about the entire event on the morning of [DATE] when they had their scheduled IDT meeting. V12 stated she was disappointed in how the staff managed the resident's care over the weekend after his fall. V12 stated they didn't do much for him. V12 stated that she met with R1's wife and son on Tuesday, [DATE]th to discuss the plan and at that point V12 recommended scheduled morphine as well as PRN and a Foley catheter. Facility policy titled Pain Management Program dated [DATE] documents the purpose to effectively manage pain to remove effects of unrelieved pain.On [DATE] at 11:40 AM, V2 DON stated that V8 did have access to the emergency medication box (E-box) to pull morphine, and that she had already educated V8 on E-box procedure for R1. V2 stated V8 should have pulled order morphine the night of the fall to provide R1 pain relief. Event ID: Facility ID: 145016 If continuation sheet Page 9 of 9