Health inspection·July 9, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect it's residents from misappropriation. This applies to three of three residents (R1, R3, R4) in the sample of nine reviewed for trust funds. Residents Affected - Few The findings include: The initial abuse investigation report dated 6/25/2025 shows a discrepancy was noted in the trust fund for R1 upon the audit of June cash dispersement. An investigation was started, the police, R1's guardian and the medical director was notified. On 7/9/2025 at 10:45 AM, V3 Regional Financial Coordinator said she was doing the quarterly account audits on 6/25/2025 because the Business Office Manager (BOM) was no longer working at the facility. V3 said she began to notice some discrepancy in the accounts. V3 said large cash withdrawals were being made for some residents, and when she asked staff if these residents usually do this, she was told no. V3 said she reported to the Administrator what she had found and the police were notified. V3 said she was still doing audits of the resident accounts and reaching out to the resident representatives to see if they had authorized the withdrawals. On 7/9/2025 at 11:00 AM, V4 Regional Director of Operations said the previous BOM (V5) was let go due to falsifying medical notes from her Doctor. V4 said V5 claimed to have brain cancer and was receiving treatments. The notes she provided to the facility to request work from home status were suspicious so the signing provider was called and it was discovered V5 was not receiving treatment for brain cancer. V4 said V3 began doing quarterly audits and noticed large withdrawals being made to some resident accounts. V4 said an investigation was started and the police were notified. V4 said V5 was called, but she did not return the call until later and when she did the police were in the building and he was able to hear what she had to say. V5 claimed she had the consent from the residents representatives to use the resident funds to buy things for them and the receipts were in her old office. V5 refused to talk to us again. The receipts were never found and the police have collected the evidence and there investigation is ongoing. V4 said R1's Guardian said he did agree to a small amount of money to be spent on R1 for new clothes. On 7/9/2025 at 12:20 PM, V8 Activity Director said she was asked by V5 to sign as a witness for cash disbursement for R1 but she never saw any money change hands. V8 said she did it because V5 asked her to. On 7/9/2025 at 1:40 PM, V7 Dietary Manager said she needed to go to the local grocery store to get milk for the facility and when she went to get the company credit card from V5, she was told they could go together since she needed to get supplies for R1. V7 said she heard V5 counting out five $20 Page 1 of 3 145295 145295 07/09/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0602 Level of Harm - Minimal harm or potential for actual harm bills. V7 said she signed the witness line on the cash disbursement log when V5 asked her to, but did not see $400 in V5's hands. V7 said while at the store, V5 picked up some incontinence briefs for R1 as well as some snacks. V7 said $20 was left, and V5 gave V7 the money telling her to hang on to it in case R1 needed anything else later. V7 said she put the money in her work desk but after the police came to interview her, she gave the money back to the Administrator. Residents Affected - Few On 7/9/2025 at 12:35 PM, V6 Police Officer said he has collected his evidence for the case and is waiting on the facility to see if anymore victims could be identified. V6 said he feels he has enough evidence to bring V5 into the station for questioning. V6 said since V5 has lied about her medical conditions, she has no receipts and the residents do not seem to have any new items in their rooms, he was suspicious of her activities as well. 1. The facility face sheet for R1 shows he was admitted to the facility with diagnoses to include dementia, epilepsy, severe intellectual disability and bipolar disorder. The facility assessment dated [DATE] shows him to have severe cognitive impairment. The resident funds statement for 4/1/2025 to 6/30/2025 shows resident cash advance withdrawals were made from his account on 5/13/25, 6/5/25 and 6/11/25 totaling $1380. The cash disbursements form for R1 shows money was withdrawn from his account on 5/9/2025 for $520 and was witnessed by V8. On 5/23/2025 a withdrawal was made for $460 and was not signed by any witness. On 6/6/2025 a withdrawal of $400 was made and witnessed by V7. On 6/18/2025 a withdrawal for $420 was made and no witness signature was found. (A total of $1800) R1 was not able to be interviewed for this investigation. R1's room was observed to not have any electronic devices, any personal care items and only a weeks worth of clothing in his closet. R1's dresser drawers were empty and only one bottle of grape soda was observed. 2. The facility face sheet for R3 shows she was admitted to the facility with diagnoses to include depression, schizoaffective disorder and dementia. The facility assessment dated [DATE] shows R3 to be cognitively intact. The resident fund statement for R3 shows withdrawals were made on 4/4/25, two on 4/14/25, 5/1/25, three on 5/13/25, two on 6/5/25 and two on 6/11/25 totaling $1250. The cash disbursements form for R3 shows a withdrawal for $60 on 4/25/2025, on 4/28/2025 a withdrawal of $40 and on 4/30/2025 a withdrawal of $180. On 5/9/2025 a withdrawal was made for $160 and on 5/21/2025 a withdrawal of $310 was made. On 6/4/2025 a withdrawal of $60 and again on 6/6/2026 another withdrawal for $40, and on 6/10/2025 a withdrawal for $40, on 6/14/2025 another withdrawal for $60 and the last one on 6/18/2025 for $10. (Totaling $1060) The withdrawals amounts are different from the resident fund statement and the cash disbursement forms. On 7/9/2025 at 2:15 PM, R3 said she does not buy things herself, her cousin buys her anything she needs. On 7/9/2025 at 2:00PM, V3 said she had spoken with R3's Power of Attorney and was told she had not authorized V5 to make purchases for R3 and would prefer R3's money stays in her bank account. 3. The facility face sheet for R4 shows she was admitted to the facility with diagnoses to include dementia, alcohol dependence, Type 2 Diabetes and delusional disorders. R4 was discharged from the facility on 6/3/2025. The facility assessment dated [DATE] shows her to be cognitively intact. The resident fund statement dated 4/1/2025 to 6/30/2025 shows cash advance payments were made on 4/14/25, 5/13/25, and two on 6/5/2025 totaling $890. The cash disbursements forms provided by the facility shows a withdrawal on 5/7/2025 for $250. On 5/21/2025 a withdrawal for $320 and on 6/3/2025 a withdrawal for $200. ( total of $770) 145295 Page 2 of 3 145295 07/09/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/9/2025 at 2:00PM, V3 said she has called the state guardian for R4 asking if approval for the withdrawal for these large funds was ok with her and she has not returned her call yet. A termination notice for V5 dated 6/23/2025 shows she was terminated from the facility on 6/23/2025 for violation of rules. Additional comments shows, [ on June 6th, you submitted a Physician note that requested an accommodation due to your serious medical condition. Accommodations was granted. Upon investigation of the June 6th note and its accuracy it was clearly altered and the letter was forged to secure accommodation that was not needed per confirmation from you provider.] The facility abuse policy with a revision date of 10/24/2022 shows this facility affirms the right of our residents to be free from abuse, neglect, exploitation and misappropriation . Types of abuse include misappropriation of resident property which means to deliberate misplacement, exploitation or wrongful temporary or permanent use of residents' belongings or money without the residents consent. 145295 Page 3 of 3