Health 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 Page 1 of 5 145295 145295 01/09/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0609 documentation of the outcome or that an investigation had been completed. Level of Harm - Minimal harm or potential for actual harm The facility Grievance Tracking Log dated January 2025 documents: R2 made an allegation of missing money on 1/5/25 with V1 AIT assigned to follow up; R3 made an allegation of missing gift cards on 1/5/25 and V3 SSD assigned to follow; and R8 made an allegation of missing gift cards on 1/7/25 and V3 SSD assigned to follow up. The facility was unable to provide any documentation that an investigation has been initiated for these residents. Residents Affected - Some On 1/8/25 at 3:00 pm the Resident Council Meeting was being held in the front sitting area. On 1/8/25 am and 1/9/25 from 9:00 am through 3:30 pm no local law enforcement was seen in the facility. On 1/9/25 at 9:51 am, V4 Activity Director stated she takes notes during the Resident Council Meetings every second Wednesday of the month. V4 stated there have been complaints during the meetings over the past few months, it's a hit and miss thing. V4 stated during the meeting if someone complains (V4) fills out a complaint form and gives it to the department that will address it. All the concerns dealing with theft I give to (V3) SSD, higher amounts greater than $22.00 or $30.00 goes to (V1) AIT. V4 stated the monthly Resident Council Meeting was held yesterday (1/8/25) and old theft reports were reviewed. On 1/8/25 at 2:50 pm, V6 Financial Coordinator stated if someone complains of missing money, she fills out a concern form, makes two copies and gives one to V3 SSD and one to V1 AIT. On 1/8/25 at 1:43 pm, V9 Contracted COTA (Certified Occupational Therapy Assistant) stated the Therapy Director is not working today and (V9) is just filling in today. V9 stated she just heard one of the residents say something about theft but does not know who the resident was and does not if it has been reported. V9 stated if someone reported theft to her, she would report it to the Therapy Director or the DON. On 1/8/25 at 1:53 pm, V10 Housekeeper stated she has heard rumors of someone stealing the resident money and if someone reported it to her, she would report it to V3 SSD. On 1/9/25 at 2:44 pm, V12 LPN (Licensed Practical Nurse) stated she has just heard rumors that residents are missing money. On 1/9/25 at 10:23 am, R11 stated yesterday in Resident Council there was talk about money and gift cards being taken. Nobody knows who is taking the money, credit cards or gift cards. They say they are investigating everything. It's been going on for quite a while. 1. On 1/8/25 at 1:14 pm, R6 stated $26.00 dollars disappeared from an envelope he had on his table, and he reported it to V14 Contracted COTA (Certified Occupational Therapy Assistant), and no one has ever asked him about it. R6 stated he has heard stories that there is a theft problem in the facility. R6 stated his roommate (R7) said he had money missing too. The facility Grievance Logs dated September 2024 through January 2025 do not document any reported allegations of misappropriation of resident property for R6. On 1/9/25 at 12:00 pm, V14 Contracted COTA (Certified Occupational Therapy Assistant) stated R6 did say something about something being missing, doesn't recall if it was money, and (V14) talked with R6 about putting things in a safe place. 145295 Page 2 of 5 145295 01/09/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/9/25 at 11:19 am V1 AIT stated she was unaware of R6 reporting missing money and does not know why it was not reported to her. 2. On 1/8/25 at 1:20 pm, R7 stated he has had money missing two times since being at the facility. The first time was about four months ago and $20.00 and recently $32.00 (R7's) brother sent (R7) that he had in a red cardinal greeting card in the top drawer of (R7's) nightstand. R7 stated he reported the money missing to V6 Financial Coordinator, filled out a form, no one ever talked to him about it, and he never found the money. On 1/8/25 during 1:20 pm conversation with R7, V5 Maintenance Director entered R7's room with a key to R7's nightstand top drawer, checked that the key would lock the drawer, handed the key to R7 and educated R7 not to lose the key. The facility Grievance Logs dated September 2024 through January 2025 do not document any reported allegations of misappropriation of resident property for R7. On 1/8/25 at 1:32 pm, V5 Maintenance Director stated all the resident nightstands have locks in the top drawer and if a resident requests a key he will give them one. V5 Maintenance Director stated R7 requested to have a key today. On 1/9/25 at 11:19 am V1 AIT stated she was unaware of R7 reporting missing money and does not know why it was not reported to her. 3. On 1/8/25 at 1:58 pm, R9 stated a couple of months ago she and her roommate (R4) had money missing. R9 stated (R9) had $20.00 missing from a coin purse in the top drawer of her nightstand and R4 had money missing from her purse. R9 stated she and R4 reported their money missing and the facility said they watched the cameras and did investigate R4's money but does not know if (R9's) money was investigated because no one talked to her about it. R9 stated, with furrowed brow, It's sad, I have no way of making that money back. The facility Grievance Logs dated September 2024 through January 2025 do not document any reported allegations of misappropriation of resident property for R4 or R9. On 1/9/25 at 11:19 am V1 AIT stated she was unaware of R9 reporting missing money and does not know why it was not reported to her. V1 AIT stated R4 reported money missing prior to discharge and it was investigated, the money was not found, and investigation was unfounded. V1 AIT stated the police were not notified. 4. On 1/8/25 at 2:05 pm, R8 stated yesterday (1/7/25) someone stole $26.00 in cash and my (restaurant) gift card. R8 stated $25.00 was taken initially and then they came back; took my last dollar and my (restaurant) gift card.R8 stated he reported it to management yesterday but can't remember her name. R8 stated no one has talked to him about it. The facility Grievance Logs dated September 2024 through January 2025 reviewed on 1/09/25 do not document any allegations of misappropriation of resident property were made by R8. On 1/8/25 at 1:35 pm, V7 RN (Registered Nurse) stated there have been some reports of residents missing money and gift cards. R8 complained about money and a gift card missing the other day and someone told the management staff already. 145295 Page 3 of 5 145295 01/09/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/9/25 at 11:19 am V1 AIT stated she was unaware of R8 reporting missing money and gift card and does not know why it was not reported to her. 5. On 1/8/25 at 2:15 pm, R2 stated she discovered $16.00 missing from the top drawer of her nightstand last weekend, reported it to V6 Financial Coordinator and no one other than V6 has talked to her about it. R2 stated she is the President of Resident Council and it (theft) happens here all the time. So many people report missing money. A lot of people won't tell, they are afraid. There are thirty some people you could ask who would tell you. R2 also stated they have had suspicions from time-to-time but can't prove anything. The facility Grievance Log dated September 2024 through January 2025 documents one entry on 1/5/25 of R2 reporting missing money and V1 AIT to follow up. On 1/8/25 at 1:55 pm, V11 RN stated a while back R2 reported that someone had taken $20.00 from her. We were told if it was less than $100.00 to report it to (V3) SSD and if over $100.00 to report to (V1) Administrator. I did report it to (V3) SSD. On 1/8/25 at 2:50 pm, V6 Financial Coordinator stated R2 complained she had $16.00 come up missing from an envelope this past weekend, she filled out a concern form, made a copy of the form, and gave one to V1 AIT and one to V3 SSD. On 1/9/25 at 11:19 am V1 AIT stated she was unaware of R2 reporting missing money and does not know why it was not reported to her. 5. On 1/9/25 at 10:00 am, R3 stated last Saturday she had two gift cards missing from her wallet that she kept in the top drawer of her nightstand. One gift card had $50.00 on it and the other one had $7.12 left on it. R3 stated she reported the missing gift cards to V6 Financial Coordinator, and no one has asked her about it since. R3 stated she feels like the facility staff do not take her seriously and she had to ask V5 Maintenance Director for a key to lock the top drawer of her nightstand that was given to (R3) yesterday (1/8/25). R3 stated theft has Been a problem here for a while. The facility Grievance Logs dated January 2025 documents R3 reported missing gift cards on 1/5/25 with V3 SSD to follow up . On 1/8/25 at 2:50 pm, V6 Financial Coordinator stated R3 reported a gift card from her wallet that was inside her bedside table was taken, (V6) filled out a concern form, made a copy of the form, and gave one copy to V1 AIT and one to V3 SSD. On 1/9/25 at 11:19 am V1 AIT stated she was unaware of R3 reporting missing gift cards and does not know why it was not reported to her. 6. On 1/9/25 at 10:13 am, R10 stated a couple of weeks ago she reported a ring missing to V4 Activity Director and the last time she remembers wearing it was 12/21/24. R10 stated she didn't wear the ring all the time and when not wearing it she kept it in the top drawer of her nightstand. The ring is very sentimental to me, and it vanished. R10 stated the ring had an almond shaped pink stone with a small diamond on each side and she has worn it off and on for two years she has been at the facility. R10 stated one of the housekeepers helped her look for the ring and they never found it. R10 stated she told V1 Administrator a while ago that she wanted someone to come and move her nightstand out of the way so she could look under it better and told V1 Administrator again yesterday (1/8/25) 145295 Page 4 of 5 145295 01/09/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0609 Level of Harm - Minimal harm or potential for actual harm and it still hasn't been moved. R10 stated in the Resident Council Meeting yesterday (1/8/25), hearing about all the money and gift cards that are missing makes me sad. It has been going on for a while now. The facility Grievance Logs dated September 2024 through January 2025 do not document R10 missing any property. Residents Affected - Some On 1/9/25 at 11:19 am V1 AIT stated R10 reported a ring missing a few weeks ago and she is having someone go down to R10's room and does not know why it isn't on the Grievance log. 7. On 1/8/25 at 1:39 pm, V8 RA (Resident Assistant) stated about three months ago R13 complained of money missing and I reported it to V3 SSD (Social Service Director). The facility Grievance Logs dated September 2024 through January 2025 do not document R13 missing money and the facility was unable to provide documentation of an investigation having been completed. On 1/9/25 at 11:19 am, V1 AIT stated she is unaware of R13 complaining about missing money and does not know why this was not reported to her. The facility Grievance Logs dated January 2025 does not document any resident grievances regarding misappropriation of resident property since 1/5/25. On 1/8/25 at 10:45 am, V1 AIT confirmed she is the Abuse Coordinator, and all abuse allegations are to be reported to her to investigate. V1 AIT stated V3 SSD holds the facility Grievance Logs and keeps them all updated with resident Grievances. V1 AIT stated V3 SSD has been out of the facility this week due to illness and V1 AIT stated (V1) was also not at the facility this week until Wednesday morning. On 1/9/25 at 11:19 am V1 AIT stated she found multiple copies of the facility concern forms in V3 SSD mailbox regarding R2, R3, and R8's allegation of theft and due to V3 SSD not being in the facility she did not receive a copy of the form and the Grievance Log had not been updated. V1 AIT also stated she does not notify local law enforcement for theft allegations because (V1) thought police were only notified of physical abuse from someone outside of the facility or the staff. On 1/9/25 at 1:00 pm, V15 Corporate Administrator confirmed all allegations of potential abuse are to be reported to V1 AIT and local law enforcement is to be notified of all resident theft allegations. 145295 Page 5 of 5