Inspection·October 1, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review and interview, the facility failed to notify the local Office of the State Long-Term Care Ombudsman and Residents/Residents' Representative in writing of resident Hospital Transfer/Discharge for five (R2, R6, R30, R34 and R291) of five residents reviewed for transfers and hospitalizations in the sample of 23. Findings include: Facility Transfer and Discharge Policy and Procedure, undated, documents that transfer or discharge documentation in the Residents clinical record shall be required. R2's Census List dated 10/1/24 documents a Hospital Paid Leave on 10/17/23, 2/26/24, 3/11/24, 4/5/24, 4/29/24, 6/4/24, 6/20/24, 7/10/24, 8/8/24 and 9/1/24. R6's Census List dated 10/1/24 documents a Hospital Paid Leave on 6/14/24 and 8/19/24. R30's Census List dated 10/1/24 documents a Hospital Paid Leave on 11/15/23, 12/20/23 and 7/3/24. R34's Census List dated 10/1/24 documents a Hospital Paid Leave on 9/20/24. R291's Census List dated 10/1/24 documents a Hospital Paid Leave on 8/24/24, 9/2/24 and 9/5/24. 1. On 10/1/24 at 12:10 pm, V9 (Social Service Manager) stated, I have never made any documentation in the medical records or sent a written notification of a hospital transfer or discharge to (V8/Ombudsman). On 10/1/24 at 12:15 pm, V8 (Ombudsman) stated, I do not receive any notification from the facility on their hospital transfers or discharges. Sometimes, when I am in the facility, they do tell me who got admitted to the hospital. I did not know that I was supposed to be notified of all the hospital discharges or transfers in writing. On 9/30/24 at 8:10 am, V2 (Director of Nursing) stated, We have not notified (V8/Ombudsman) of resident hospital transfers or discharges. On 10/1/24 at 10:50 am, V1 (Administrator) stated, We do not email or notify (V8/Ombudsman) of hospital transfers or discharges. As you know, the facility has been in the middle of new ownership transition, so I cannot give you a specific policy for Transfer Discharge to hospital on notifying the Office of the State Long-Term Care Ombudsman. (continued on next page) 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 6 Event ID: 145239 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 145239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614 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)