Health inspection·April 10, 2025

F 0684 appearance the wound is worsening and appears deeper. Level of Harm - Actual harm On 12/16/24 the wound assessment shows it is 2.00 cm. x 1.30 cm. with a surface area of 2.60 cm and the wound photo shows what appears to be slough beginning in the wound bed. Residents Affected - Few On 12/30/24 the wound assessment shows there is now a moderate amount of serous drainage to the wound bed. On 1/13/25 the wound is now 3.0 cm x 3.0 cm and a total wound surface area of 9.0 cm. R1's 12/1-12/31/24 TAR shows a treatment order change for the wound that was given on 12/18/24 by V3 (Wound Care Physician). R1's Physician Progress notes show V14 (former facility Nurse Practitioner) documented R1's wound on 12/3/24 and described it as dry cracked skin to left heel and documents not healing. R1's 12/26/24 physician note refers to R1's wound and states she was provided with a diabetic shoe. Neither note shows that V14 saw R1 or that she was informed of the wound deterioration. R1's Progress note completed by V15 (R1's Physician and Medical Director) on 12/28/24 states, no issue is noted per nursing staff and does not mention R1's wound. The first wound care assessment documented by V3 was not until 1/14/25 and the wound was then described as 3 cm x 3 cm x 0.1 cm and has heavy serous drainage and 90% necrotic tissue and 10% slough. On 4/8/25 at 12:17 PM, V3 said he was not able to recall when he first saw R1 but said he should be contacted to see a resident if the wound shows heavy drainage, signs it is not healing, increased size or signs of necrosis. V3 said R1 would allow him to assess her wound and do treatments like debridement for the wound. V3 described her wound as a full thickness with soft necrosis. V3 reviewed his assessments with the survey and agreed his first assessment for R1's wound was on 1/14/25. On 4/9/25 at 9:25 AM, V8 said she was aware that the order for the Triple Antibiotic Ointment was not carried out on time. V8 said the nurse who got the order did not enter it into the EMR so it was missed until she caught it and added it to the treatments. V8 said in her opinion 12/10/24 was the start of the deterioration of R1's wound. V8 said she did not call to report this to anyone because R1 was supposed to have a podiatry appointment on 12/11/24 but R1 canceled that appointment and canceled again on 12/18/24. V8 said she called V3 to get an order to change the treatment for R1's wound care on 12/18/24. V8 said she would call a physician if a wound increases in size, is not healing, has heavy drainage or has signs of an infection. V8 did not call V5 or V14 to report the wound condition change. V8 said V3 first saw R1 on 1/14/25. V8 said initially R1 wanted to be seen by her own outside provider (V5) but there is nothing documented in R1 EMR's showing she refused the services or to be seen by V3. V8 also said R1 had been in the hospital from 12/22-12/25/24 and again from 1/6/25-1/12/25 for non related medical issues. On 4/9/25 at 11:17 AM, V5 said he did see R1 on 11/6/24 and gave orders for her to start the Triple Antibiotic Ointment daily to her wound. V5 said no one from the facility called to report that this was not started (until 9 days later) and this was a concern because this medicated ointment is an antibiotic to prevent infection, and by R1 not receiving it bacteria could build up in her wound bed. V5 also said no one contacted him to report the worsening wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145295 If continuation sheet Page 2 of 3 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 04/10/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few The facility provided Skin Condition Assessment & Monitoring- Pressure and Non-Pressure last revised 6/8/18 shows when there is changes to a wound physicians should be notified and that should be documented in the residents clinical record. Changes described that would require notification include onset of drainage, odor, cellulitis, increased pain, increase in wound measurements and onset of new ulcers. The facility provided Entering and Processing orders policy last revised on 1/31/18 shows after a physician visit the nurse should check for orders and the order will be completed and entered into the EMR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145295 If continuation sheet Page 3 of 3