Health 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. Page 1 of 6 145239 145239 10/01/2024 Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. On 10/1/24 at 12:10 pm, V9 (Social Service Manager) stated, I have never made documentation in the medical records or sent a written notification of a hospital transfer to any family or resident. On 9/30/24 at 8:10 am, V2 (Director of Nursing) stated, We do not mail or notify residents or their Representatives in writing of a hospital transfer. There is no documentation in the residents' charts that any of these notices have been sent either. I cannot find any copies of any notification to the Resident Representatives for any of our residents that discharged to the hospital. On 10/1/24 at 10:50 am, V1 (Administrator) stated, We do not send written notifications to the residents or the Representatives when a Resident goes out to the hospital and there is no documentation in the medical record either. 145239 Page 2 of 6 145239 10/01/2024 Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a new/updated PASARR (Preadmission Screening and Resident Review) Level II for one (R30) of two residents reviewed for PASARR screenings in a sample of 23. Residents Affected - Few Findings include: On 10/1/24 at 1:30 pm, V1 (Administrator) stated, I am unable to provide a PASARR Policy; we do not have a PASARR Policy. R30's Physician Order Summary Report, dated 10/1/24, documents an admission dated of 12/31/23 and medication orders (Venlafaxine Hydrochloride and Aripiprazole) for diagnoses including Major Depressive Disorder, Severe Psychotic Symptoms, Bipolar Disorder, Unspecified Psychosis and Delusional Disorder. R30's Notice of PASARR Level II Screen Outcome, dated 7/31/23, documents the date of Short-Term Approval ends on 10/29/23. The PASARR Outcome Explanation documents that this Level II evaluation is good within 90 calendar days of the Notice Date listed on the PASARR Level II Outcome and after that time, you must have an updated Level I and Level II before you to go to a Medicaid Certified Nursing Facility. On 10/1/24 at 1:30 pm, R30's Medical Record did not document an updated PASARR, and the Facility could not produce an updated PASARR. On 10/1/24 at 1:30 pm, V2 (Director of Nursing) stated, We need to update this PASARR. I just noticed that it was no longer effective after 10/29/23 and was for a short stay. I will get it updated. 145239 Page 3 of 6 145239 10/01/2024 Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to hold Quality Assurance (QA) and Improvement Committee Meetings. This failure has the potential to affect all 40 residents who currently reside in the facility. Residents Affected - Many Findings Include: The Facility's Quality Assurance and Improvement Agenda dated 4/19/2019 documents that the following areas will be reviewed as a Quality Assurance Team at least every quarter: Resident Concerns, Consultant/Department Reports, Policy and Procedure Review and Updates, Nursing and Quality Improvement Information, Special Unit Report (if applicable), Dietary Report, Social Service Report, Activity Department, Housekeeping and Laundry, Quality Assurance Audits/Rounds, Surveys Compliance, Life Safety Concerns, Safety Issues/Risk Management, Personnel, Environmental Improvements Planned/Made during the Quarter, Census/marketing Recruitment. On 10/01/24 at 12:15 PM, V1 (Administrator in Training) stated I have no documentation of any QA meetings done prior to me coming in April 2024. I held one immediately upon hire because I did not see where it had been getting done. The facility's Long-Term Care Application for Medicare and Medicaid dated 9/29/24 documents 40 residents currently reside in the facility. 145239 Page 4 of 6 145239 10/01/2024 Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to monitor infections. This failure has the potential to affect all 40 residents that currently reside in the facility. Residents Affected - Many Findings Include: The Facility's Infection Control Surveillance and Monitoring policy dated 4/11/2022 documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. Monitoring of the day-to-day operation of the Infection Control Program will be conducted by the DON/ICP (Director of Nursing/Infection Preventionist). Included in the duties are: Investigation and implementation of controls to prevent infections in the facility, determine and direct the correct procedures necessary for the prevention of infections. This shall be done on an individual basis, applying the concepts of isolation per infection, follow up on documentation of, and reporting of infection to physicians, through direct, random inspections of the clinical record with respect to: 1) Isolation techniques initiated and followed, 2) Evaluation of parameters involved in assessment of physical condition are evaluated and reported as appropriate (vital signs, evaluation of infection site, resident response to isolation techniques, etc.), 3 Periodic observation of infection sensitive techniques, including soaks, irrigations, catheter procedures, intravenous infusions, tracheostomy procedures and inhalation techniques The Facility's Infection Control Monitoring Logs provided started with April 2024. On 10/01/24 at 10:00 AM, V2 (Director of Nursing) stated, I started here (at the facility) in April 2024, I do not know where (V10/ previous Director of Nursing) kept any of her documentation of the facility's infections. I have no further documentation prior to April 2024. The facility's Long-Term Care Application for Medicare and Medicaid dated 9/29/24 documents 40 residents currently reside in the facility. 145239 Page 5 of 6 145239 10/01/2024 Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program. This failure has the potential to affect all 40 residents that currently reside in the facility. Residents Affected - Many Findings Include: The facility's Antibiotic Stewardship Program Protocol dated 12/12/18 states, Purpose: To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished using the Core Elements. Core Elements for Antibiotic Stewardship: 1. Leadership Commitment: Demonstrates support and commitment for safe and appropriate antibiotic use. Accountability: Identify physicians, nursing, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities. Action: Implement as least one policy or practice to improve antibiotic use. Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use. Reporting: Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff. As of 10/1/24, the facility was unable to provide any documentation that antibiotic tracking or infection surveillance had been completed prior to September 2024. On 10/01/24 at 10:00 AM, V2 (Director of Nursing) stated that prior to September 2024, there was no monitoring of antibiotics or infection surveillance being completed. V2 stated V2 would have expected a McGreers Criteria Data Tool Form to be filled out on every antibiotic ordered at the facility to ensure it met Antibiotic Stewardship Protocols. V2 stated that V2 had to bring in Pharmacy to educate the nurses on what Antibiotic Stewardship even was. The facility's Long-Term Care Application for Medicare and Medicaid dated 9/29/24 documents 40 residents currently reside in the facility. 145239 Page 6 of 6