Health inspection·May 11, 2022

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a PASARR (Preadmission Screening and Resident Review) Level II screening for three of three residents (R37, R58, R69) reviewed for PASARR screenings in the sample of 33. Residents Affected - Few Findings include: The facility's Preadmission Screening and Annual Resident Review policy, dated 11/17/17, documents, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the PASARR screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder, intellectual disability or related condition. Based upon the Level 1 screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. The policy also documents, If the facility disagrees with the specialized services and PASARR recommendations, it will document the rationale in the medical record. The facility may apply for Level II reconsideration. 1. R37's Physician's orders, dated 5/11/22, document that R37 was admitted to the facility on [DATE], and has the following diagnoses: Psychosis, Generalized Anxiety, and Major Depressive Disorders. R37's OBRA Initial Assessment, dated 6/17/18, documents that there is reasonable basis for the suspicion of R37 having a MI (mental illness) or DD (developmentally disabled). The assessment also documents, Yes the individual has been formally diagnosed with a mental illness verified by a DSMIV classification which substantially impairs the persons cognitive, emotional and/or behavioral functioning. However, there is no documentation of a Level II PASARR screening being completed. R37's Care plan, dated 7/29/21, documents, I have a history of criminal behavior. I was arrested in 1985 for criminal sexual assault and home invasion. In 1992 (R37) was convicted for manufacturing and delivery of drugs. I have demonstrated stability during the admission screening process, and does not appear to present at risk. fits the criteria for an 'Identified offender. R37's Care plan, dated 7/29/21, documents, I am a non-reliable responder due to my history of visual hallucinations. I will hallucinate in a sexual way about staff members, and I make false accusations about these hallucinations and other beliefs. 2. R58's Physician's order, dated 5/11/22, documents that R58's most recent admission was 1/29/22, and R58 has the diagnoses of Intellectual Disabilities and Schizoaffective disorder. R58's Careplan, dated 1/14/22, documents, I have impaired cognitive function/dementia or impaired thought processes related to difficulty making decisions, impaired decision making, intellectual disabilities. R58's OBRA Initial Assessment, dated 11/1/10, documents that R58's initial admission to the facility was on 11/3/10, and there is reasonable basis for the suspicion of R58 having a MI (mental illness) or DD (developmentally disabled). The assessment also documents, The individual has been formally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 2 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnosed with Mental Retardation and the condition manifested prior the the age of 22, and the individual has received special education and/or day program services. However, there is no documentation of a Level II PASARR screening being completed. 3. R69's Physician's orders, dated 5/11/22, document that R69 was admitted to the facility on [DATE], and R69 has the diagnoses of Schizoaffective disorder, Bipolar disorder manic severe with psychotic features, and Major Depressive Disorder. R69's OBRA Initial Assessment, dated 7/24/21, documents that there is reasonable basis for the suspicion of R69 having a MI (mental illness) or DD (developmentally disabled). The assessment also documents, Yes the individual has been formally diagnosed with a mental illness verified by a DSMIV classification which substantially impairs the persons cognitive, emotional and/or behavioral functioning, has a history of psychiatric hospitalizations, and history of outpatient health services. R69's Level I Notice of Determination, dated 7/26/21, documents, R69 has a past history of mental health issues. Has a current diagnosis of Bipolar Disorder, and was admitted to hospital with complaints of pain. R69 appropriate for nursing facility for 120 days, with additional screen if stay is extended. However, there is no documentation of an additional screen being completed nor a Level II screening. On 05/11/22 at 11:58 AM, V3 (Business office manager) stated, I receive the OBRA screen, then I hand them off to social services unless there is a cut off date. R69 did not have another OBRA/Level II done. On 05/11/22 at 12:01 PM, V7 (Social Services Director) stated, I don't get the OBRA/PASARR screens. I don't even know what you're talking about. I don't know who (R58) even is. On 05/11/22 at 12:40 PM, V5 (Cooperate Nurse) stated, I know (R58) had to have one because he came from a (DD) Developmentally disabled group home. V5 confirmed Level II were not completed for R37, R58, and R69. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 3 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow a physician ordered treatment, and perform hand hygiene during wound care for one of two residents (R69) reviewed for non-pressure ulcer wounds in the sample of 33. Residents Affected - Few Findings include: The facility's Skin Condition Assessment & Monitoring Pressure & Non-Pressure policy, dated 6/8/18, documents, Conduct hand hygiene in accordance with facility standard/universal precautions. The policy also documents, Physician ordered treatments shall be initiated by the staff on the electronic Treatment Administration Record after each administration. The facility's Hand Hygiene/Handwashing policy, dated 1/20/20, documents, Examples of when to perform hand hygiene: After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressing. R69's Current Electronic Physician's orders, as of 5/9/22, document an order to cleanse R69's wound to the top of R69's foot with wound cleanser, pat dry, apply Leptospermum honey and collagen, and cover with dry dressing every day shift. R69's Care plan, dated 5/9/22, documents, I currently have an arterial wound to top of left foot. The care plan also documents the following intervention, Provide wound care per treatment order. R69's Wound Evaluation & Management Summary, dated 5/3/22, documents, R69 presents with a wound on his left, dorsal foot. Arterial wound of the left dorsal foot full thickness. Wound size: 4.2 cm (centimeters) x 2.4 cm x 0.1 cm. The summary also documents the following dressing treatment plan: Primary dressing-Leptospermum honey and collagen sheet; Secondary dressing-gauze island with border to be completed three times a week. On 05/09/22 at 12:20 PM, V8 (Registered Nurse) removed soiled gauze border dressing from R69's left foot. R69's dressing had moderate amounts of brown drainage. Then, V8 picked the brown saturated collagen sheet from R69's wound. Without changing her gloves and performing hand hygiene, V8 cleansed R69's wound with normal saline. Then, R69 removed her gloves and performed hand hygiene. Then, V8 applied the Leptospermum honey with her gloved finger, covered with a sheet of collagen, and then a boarder foam dressing. V8 stated, The dressing I took off was a border gauze and the one I just put on is boarder foam. It doesn't matter which one I use. I just have to cover it with a dressing. V8 confirmed that she did not change gloves or perform hand hygiene after removing the soiled dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 4 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provide ROM (Range of Motion) restorative programming for one of two residents (R37) reviewed for ROM in the sample of 33. Residents Affected - Few Findings include: On 05/09/22 at 12:40 PM, R37 was alert sitting up in his wheel chair in the dining room. R37's left hand was contracted into a closed position. R37 stated, I'm contracted at the elbow as well. Demonstrating that he was unable to move his elbow from a 90 degree angled position. R37 stated, I'm supposed to have surgery on my elbow sometime because of it. They don't do any elbow or hand exercises with me whatsoever, but it would probably help. R37's Orthopedist note, dated 3/22/22, documents, The following issues were addressed: left elbow pain; contractor of muscle, left upper arm; entrapment of left ulnar nerve; hemiplegia of left nondominant side as late effect of cerebrovascular disease. R37's Therapy screening, dated 3/8/22, documents, R37 has continued difficulty with wheel chair seating, mobility, and left upper pain and contractor. Physical/Occupational/Speech Therapy is recommended. However, R37's medical record has no documentation of R37 receiving a therapy evaluation or treatment. R37's Electronic CNA(Certified Nursing Assistant) tasks have no documentation of R37 receiving any ROM restorative programming. On 05/11/22 at 12:12 PM, V2 (Director of Nursing) stated, We do not have a formal ROM assessment in the facility, so (R37) doesn't have an actual ROM assessment, but he does have contractures. (R37) isn't on any ROM programming. V2 confirmed that the facility does not have a policy regarding contractures and ROM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 5 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post the current nurse staffing information with actual nursing staff working. This failure has the potential to affect all 74 residents residing in the facility. Residents Affected - Many Findings include: On 5-10-22, at 2:30pm, the facility's Daily Staffing Requirements sheet was posted near the entrance of the resident halls and nurse's station and dated 5-10-22. On 5-10-22, at 2:37pm, V3 Business Office Manager/BOM stated the following: (V3) is the one who posts the sheet and was told to put the numbers in and it would automatically calculate the numbers. At this time, (V3) confirmed it does not reflect the actual working staff. It was explained to me (V3) that it will show required staff. On 5-10-22, at 2:43pm, V2 Director of Nursing/DON confirmed that the actual staff hours worked are not on the Daily Staffing posting. V2 stated that any changes made are on the schedule, not on the Daily Staffing posting. I didn't know it was supposed to be. The facility's Resident Census and Conditions of Residents dated 5-9-22 documents 74 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 6 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to a implement personalized dementia program for one of one (R40) residents reviewed for dementia care in a sample of 33. Residents Affected - Few Findings include: R40's current face sheet documents a diagnosis of Vascular Dementia with behavioral disturbances. R40's current care plan does not address R40's Vascular Dementia, or specialized activities for R40. On 5/9/22 at 10:00am, R40 was in bed sleeping. At 12:00pm, R40 was sitting up eating lunch. R40 is very friendly and talkative. At 2:00pm, R40 remained friendly and cooperative. On 5/10/22 at 9:00am, R40 was in bed sleeping. At 2:30pm, R40 remained in his bed, R40 stated that he just likes to talk to people, but they don't have time. On 5/11/22 at 9:00am, R40 remained in bed sleeping. At 12:00pm, R40 was in bed eating lunch. At 1:30pm, R40 remained friendly and talkative. During the survey no adverse behaviors were observed from R40. Multiple observations were made of R40 from 5/9/22 to 5/11/22, at various times of the day. R40 did not leave his room, nor were any one on one activities were offered. On 5/10/22 at 1:50pm, V1 Adminsitrator verifies that the facility does not offer specific programing for residents with a diagnosis of dementia. On 5/11/22 at 10:00am, V2, Director of Nursing, stated that R40 stays to himself in his room. V2 verified that one on one activities are not offered and the facility does not have specialized Dementia Programs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 7 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 monitor for the adequate effectiveness of insulin and for anticonvulsants used for psychotic disorders for three of 18 residents (R54, R74 and R75) reviewed for medication monitoring in the sample of 18. Residents Affected - Few Findings include: The facility policy, Psychotropic Medication- Gradual Dosage Reduction, dated (revised) 2/1/18 directs staff, To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. 1. On 05/09/22 at 10:44 AM, R54 was alert and oriented sitting up in his bariatric bed. R54 stated, I had some recent blood sugar issues that they had to manage because I was refusing my insulin. R54's Physician's orders document that R54 has an order to receive Basaglar 76 units subcutaneously daily at bed time, blood glucose monitoring every morning, a no concentrated sweets diet for the diagnosis of Type 2 Diabetes Mellitus. R54's Physician's orders also have an order for R54 to have a CMP (Comprehensive Metabolic Panel) blood draw on 1/6/22 all for the diagnosis of Type 2 Diabetes Mellitus. However, R54's medical record has no documentation of the results of the CMP. R54's Care plan, dated 2/15/22, documents, I have Diabetes Mellitus insulin dependent. Goal: I will have minimal complications related to diabetes through the review date. R54's MAR (Medication Administration Record), dated 5/2022, documents that for the month of May (1-11th) R54 had blood glucose level checked in the morning and then in the evening prior to his insulin injection. R54's results of the blood glucose level ranged from 177-493 with 19 out of 21 being over 200. R54's current electronic record has no documentation of monitoring for the effectiveness of R54's insulin usage. On 05/11/22 at 12:12 PM, V2 (Director of Nursing) stated, I would expect if (R54) was diabetic and receiving insulin therapy I would expect a HGA1C (Hemoglobin A1C) and CMP to be completed. It was ordered for (R54) to get a CMP in [DATE] but for some reason it was canceled, and I don't know why. 2. R74's current Physician Order Sheet, dated May 2022 includes the following diagnoses: Anxiety Disorder, Schizoaffective Disorder Bipolar type. This same document includes the following physician orders: Depakote ER (Valproic Acid) (antipsychotic)Tablet Extended Release 24 Hour 500 MG (milligrams) Give 2 tablets by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. Valproic Acid level on 8/9/2021 and every six months. R74's current Care Plan, dated 8/30/2021 includes the following Care Areas: Psychotropic medications. This same document also includes the following Interventions: Administer medications as ordered and monitor for any adverse effects. Report to Physician as needed. A review of R74's electronic Medical Record shows no Valproic Acid levels, as ordered by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 8 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0757 Physician. Level of Harm - Minimal harm or potential for actual harm 3. R75's Physician Order Sheet documents for R75 to take Depakote (Anticonvulsant Residents Affected - Few Sprinkles Delayed Release capsule 125mg (Milligram) twice daily for Schizophrenia. R75's medical record does not contain a Depakote or Valporic Acid level to monitor the therapeutic levels of the Depakote Sprinkles. On 5/11/22 at 10:00am, V2 verified that R75 has not had a Valporic Acid level done, to monitor the therapeutic blood level of R75's Valporic Acid level in the last year. V2 stated that the facility does not have a specific policy, but they should be done at least every 6 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 9 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify adverse reactions to an antipsychotic medication and document a diagnosis nor behaviors to warrant the use of an antipsychotic for two of six residents (R13, R40) reviewed for psychotropics in the sample of 33. Findings include: The facility policy, Psychotropic Medication- Gradual Dosage Reduction, dated (revised) 2/1/18 directs staff, To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. The facility's AIMS Side Effect Monitoring policy, dated 1/11/18, documents, Abnormal Involuntary Movement Scale (AIMS) records the occurrence of tardive dyskinesia (TD-a neurological disorder characterized by involuntary movements of the face and jaw) of residents receiving psychotropic medications. To assess the presence of movement and non-movement side effects, and to follow the severity of TD over time. The policy also documents, Assessment results will be conveyed to attending psychiatrist and Nurse Practitioner when abnormal findings or increasing in severity and side effects is noted. 1. R13's Physician's orders, dated 5/11/22, document that R13 has an order to receive Risperdal (antipsychotic) 5 mg (Milligrams) by mouth at bedtime for the diagnosis of Paranoid Schizophrenia dated 7/20/21. On 05/09/22 at 10:38 AM, R13 was alert sitting up in her wheel chair in her room. R13 was alert and oriented, however at times would become delusional thinking she was pregnant. R13 had tremors at rest in R13's in bilateral hands. R13 occasionally would have a pill roll action with her left thumb and index finger. R13 also had a towel around her neck and was notable drooling. On 05/11/22 at 11:55 AM, R13 was alert sitting up in her wheelchair at the dining room table. R13 had tremors to R13's bilateral hands, and was pill rolling her left thumb and index finger. R13 was also notably drooling. R13's Care plan, dated 7/27/21, documents, I use anti-psychotic medications, Risperdal related to Diagnosis of Paranoid Schizophrenia with delusions and hallucinations. The care plan also documents the following goal: I will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment while on lowest effective dose. An intervention to help achieve the goal was Monitor/document/report PRN (as needed) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (Extra pyramidal symptoms-shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. R13's AIMs scale, dated 3/10/21, documents a score of 0 no abnormalities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 10 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0758 Level of Harm - Minimal harm or potential for actual harm R13's AIM scale, dated 9/10/21, documents a score of 6 due to: Mild jaw, e.g. biting, clenching, mouth opening, lateral movement; moderate upper extremity and lower extremity movements; Severity of abnormal movements-mild; Incapacitation due to abnormal movements-mild; resident's awareness of abnormal movements-awareness with mild distress. R13's current medical record has no documentation of R13's physician being notified of R13's change in abnormal movements. Residents Affected - Few R13's AIM Scale, dated 3/10/22, documents a score of 3 due to: minimal muscles of facial expression movements; minimal lips and perioral area movements; minimal jaw movements. On 05/11/22 at 12:12 PM, V2 (Director of Nursing), confirmed that there was a change in R13's AIMs scores. V2 stated, If there is a change the nurse should notify the physician and make a note in the nurses' notes regarding the change. 2. On 5/9/22 at 10:00am, R40 was in bed sleeping. At 12:00pm, R40 was sitting up eating lunch. R40 is very friendly and talkative. At 2:00pm, R40 remained friendly and cooperative. On 5/10/22 at 9:00am, R40 was in bed sleeping. At 11:00am, R40 was stating that he needed his bandage put on his back wound. R40 was cooperative and friendly during wound care. At 2:30pm, R40 remained in his bed, R40 stated that he just likes to talk to people, but they don't have time. On 5/11/22 at 9:00am, R40 remained in bed sleeping. At 12:00pm, R40 was in bed eating lunch. At 1:30pm, R40 remained friendly and talkative. During the survey no adverse behaviors were observed from R40. R40's current POS, Physician Order Sheet, documents to take Quetiapine Fumarate (Antipsychotic) 50mg three times daily, for the diagnosis of Vascular Dementia with behavioral disturbances. R40's current care plan does not document any adverse behavioral goals or interventions. R40's medical record does not document any adverse behaviors, nor attempted gradual dose reductions of a psychotropic medication. since admission on [DATE]. 05/11/22 09:10am, V2, Director of Nursing stated that R40 has not had any adverse behaviors at all and there is no documentation in his medical record. V2 also verified that R40's care plan does not contain adverse behavioral goals and interventions. V2 also stated that R40 has not has a gradual dose reduction done since his admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 11 of 12 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 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to conduct quarterly Quality Assurance meetings with the required members present. This failure affects all 74 residents in the facility. Residents Affected - Many Findings include: The facility's QA (Quality Assurance) Committee meeting sign-in sheets, provided by V1 Administrator, dated 1-21-22 and 4-2-22, document the facility conducted these two QA meetings without the Medical Director's attendance. The sign-in sheets, dated 1-21-22 and 4-2-22, do not document V4 Medical Director's signature. On 5-11-22, at 10:45am, V1 Administrator confirmed that V4 Medical Director did not attend the QA meetings in January 2022 or April 2022. V1 stated that V1 was not yet working here for the January meeting and did not send (V4) any notes from the April meeting. The facility's Resident Census and Conditions of Residents dated 5-9-22 documents 74 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 12 of 12