Health inspection·February 14, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident (R1) from sexual abuse by (R2). This applies to 1 of 3 residents reviewed for abuse in the sample of 4. The findings include: R1's electronic face sheet printed on 2/14/25 showed R1 has diagnoses including but not limited to Alzheimer's disease, anxiety disorder, and insomnia. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment. R1's care plan dated 1/24/25 showed, Problematic manner in which I act characterized by inappropriate sexual behavior (verbal or physical) related to need for affection, need for attention, resident touches other residents. I initiate contact with other residents resident given a baby doll for companionship, distract resident if possible . R2's electronic face sheet printed on 2/14/25 showed R2 has diagnoses including but not limited to dementia with agitation, congestive heart failure, pulmonary edema, and alcoholic cirrhosis of the liver. R2's facility assessment dated [DATE] showed R2 has no cognitive impairment. The facility's abuse investigation dated 1/28/25 showed, (V4-Physcial Therapist) reported to abuse coordinator that she witnessed (R2) with his hand under (R1's) sweater. (V4) immediately separated the residents. Interview with (R2) revealed confusion on his part about who (R1) is as he thought and referred to her by a different name .Upon review of the camera footage, (R1) propels herself to (R2) and reaches out her hand and places his hand under her sweater. (R1) doesn't pull away, but staff immediately intervened. Surveyor requested to view the facility's video footage but (V1-Administrator) stated the footage was now unavailable as it is only saved for a short period of time. (Incident occurred on 1/23/25) R2's social service note dated 1/23/25 showed, Writer spoke with resident who was in a relaxed good mood. Resident states he was dreaming of living in his 20s and was sorry . The social worker who spoke with R2 no longer works at facility and was unable to be interviewed. (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 2 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 02/14/2025 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)