Inspection·January 9, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview, and record review the facility failed to report potential allegations of theft to the Abuse Coordinator and local law enforcement for 12 (R1 through R10 and R12 through R13) of 12 residents reviewed for misappropriation of resident property in the sample of 13. Findings include: The facility Abuse Prevention policy and procedure, dated 10/24/22, documents the facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belonging or money without the resident's consent. This same policy documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In addition to the administrator the facility shall also contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations: . When there is a reasonable suspicion that a crime has been committed in the facility by a person other than a resident. This policy also documents If there is a reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then a report to local law enforcement and (State Agency) as soon as possible but within 24 hours of when the suspicion was formed. The final investigation report shall contain . the police report. The facility Grievance Logs dated September 2024 through January 2025 documents R1, R4, and R5 were the only residents who made allegations of theft. The facility provided all the abuse investigations the facility has completed between September 2024 through January 2025. R1, R4, and R5 were the only investigations regarding potential theft that were investigated. The facility Grievance Tracking Log dated September 2024 documents R5's allegation of missing $88.00 on 9/16/24 and V1 AIT (Administrator in Training) and V3 SSD (Social Service Director) assigned to follow up. The facility Grievance Tracking Log dated October 2024 and November 2024 do not document any potential theft allegations having been made. The facility Grievance Tracking Log dated December 2024 documents R12 made an allegation of missing $80.00 on 12/25/24 and V3 SSD assigned to follow up. The facility was unable to provide (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 5 Event ID: 145295 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 145295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341 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)