Inspection·August 6, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to address concerns voiced by residents during their resident council meetings. This failure has the potential to affect all forty-six residents who reside in the facility. The facility's Grievances policy dated 9/25/2017 documents the policy's purpose as to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. All alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, will be immediately reported to the administrator and as required by state law. The facility's Grievances policy also documents All written grievances shall include: The date the grievance was received; a summary statement of the grievance; department assigned to investigate; steps taken to investigate the grievance; summary of the pertinent findings or conclusions regarding the concern(s).statement as to whether the grievance was confirmed or not confirmed; corrective action taken or to be taken by the facility as the result of the grievance, including measures taken to prevent further potential violations of any resident right while the alleged violation is being investigated; the date the written decision was issued to the resident or the complainant. The facility's Grievances policy also documents Every effort shall be made to resolve grievances in a timely manner, usually within 5 business days (excludes weekends and holidays). Under certain circumstances, additional time may be needed to complete an investigation and implement measures to resolve grievances. In such cases, the resident or complainant should be notified of the extension. An appointed Grievance Official (usually the Social Services Director) is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations and maintaining the confidentiality of all information associated with grievances. The Facility's Resident Council dated February 2025 documents Nursing: (Medications) not getting passed some days on the east side. CNA (Certified Nursing Aide) not checking residents, talking on their phones in the rooms, not passing ice and drinks, not answering call lights, talking about outside stuff in front of residents, not feeding the feeders. The Facility's Resident Council dated March 2025 documents CNA: not answering call lights, turning call lights off without getting help, being told you are not mine today, feeders not being fed. The Facility's Resident Council dated April 2025 documents Nursing: (Medications) not being passed at right time CNA: some people being told to do their own (cares). The Facility's Resident Council dated May 2025 documents Housekeeping: Housekeepers telling residents they have a job, can't help them. Nursing: (Medications) not passed in the (morning) Friday and Saturday of last week.The Facility's Resident Council dated June 2025 documents CNA: (first) shift not doing as they should, not getting walked when needed. The Facility's Resident Council dated July 2025 documents CNA: being told not my resident. The Facility's Concern/Compliment Form dated 6/27/25 documents that R7 reported that he did not remember Residents Affected - Many (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 3 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 08/06/2025 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)