Health inspection·July 9, 2025

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 The cash disbursements form for R1 shows money was withdrawn from his account on 5/9/2025 for $520 and was witnessed by V8.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) (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 07/09/2025 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)

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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145295 If continuation sheet Page 3 of 3