Health inspection·May 2, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based upon observation, interview and record review, the facility failed to provide clean, stain-free linens for bathing for 9 residents (R7, R15, R22, R25, R30, R32, R44, R48 and R57) of 9 residents reviewed for dignity, in a sample of 30. The facility policy, Dignity, dated (reviewed) 4/23/18 directs staff, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. 1. On 4/29/24 at 10:38 A.M., R44 held up two (2) discolored wash clothes which had brown/tan stains. R44 stated Would you want to wash yourself with these? This is gross. This is supposed to be my house and I sure wouldn't use this to wash my car. It's not dignified. I even posted pictures on (Social Media). Ever since this new company took this place over, they can't get wipes, so they (staff) have to wipe our a***s with them. Then they just put them right back in the laundry. I bet those washing machines are full of feces and that's not right. Go culture them and see what grows out of them. I feel so contaminated 2. On 4/29/24 at 9:46 A.M., R25 was seated in her wheelchair, in her room. At that time, R25 stated, I'm so upset about this. Look at this filthy washcloth. Staff brought this into my room this past weekend and wanted me to use it to wash my face. It's a dignity problem. It is so undignified to even think of using something that someone else used to wipe their butt with. They took away our disposable wipes and told us we have to use these stained up washcloths. Last week when I went to take my shower, they wanted me to sit on a community shower chair that was covered with a blood stained white towel. R25 held up a greyish-looking washcloth covered with brown stains. On 4/29/24 at 10:55 AM, V7 (Housekeeping Manager) stated If the laundry is stained after we wash it, we pull it out and give it to housekeeping or the kitchen to use as rags. Over there (pointed at multiple boxes on clean side of laundry room) are full of brand new towels and wash clothes. If it is really bad (dirty washcloth), the CNA's are suppose to wash it in the hopper and put it in a bag before they put it in the laundry. It gets cleaned with all other whites. Soiled (wash clothes saturated with brown substances.) laundry was observed in the laundry bin in front of the washing machine. V7/Housekeeping Manager verified the laundry in the bin with the soiled material was ready for wash. 3. On 4/29/24 at 2:47 P.M., V48 stated, I am the (facility) Resident Council President. Many residents have voiced concerns to me about dingy, brown stained washcloths that we are given for bathing. We feel demeaned by being forced to use (feces) stained washcloths to wash ourselves. Page 1 of 9 145413 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/30/24 at 1:00 P.M., during the facility Group Meeting, R48 stated, Please do something about these dirty, stained wash cloths they make us wash with. It is demeaning to be treated this way. At that time, the other residents in attendance (R7, R15, R22, R30, R32 and R57) were in agreement. On 4/30/24 at 2:40 P.M., V1/Administrator stated, Our company policy is that we no longer buy (disposable) wipes for incontinence care. Staff have to use washcloths for peri care. They're not supposed to use the stained ones. I will talk to laundry and remind them to throw the stained ones away. 145413 Page 2 of 9 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of two residents (R2) reviewed for PASARR screening, in the sample of 30. Findings include: The facility policy, Preadmission Screening and Annual Resident Review (PASARR), reviewed 11-13-18 documents, It is the policy to screen all potential admissions on a individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criteria for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Annually and with any significant change of status, the facility will complete the PASARR Level 1 screen for those individuals identified per the Level 11 screen requiring specialized services. R2's current Physician Order Sheet, dated May 2024 documents that R2 was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder and Major Depressive Disorder. R2's current PASAAR screen, provided by V2/Director of Nurses on 4/29/24, documents R2 was originally admitted to a Skilled Nursing Facility on 3/26.97 with no diagnosis of Severe Mental Illness. On 4/29/24 at 12:27 P.M., V2/Director of Nurses verified that R2 has not had a PASAAR rescreen upon admission to the facility, despite R2's diagnoses of severe mental illness. 145413 Page 3 of 9 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview, observation and record review, the facility failed to ensure a resident was safely during transport in the facility's transport van for one of two residents (R7) reviewed for falls in the sample of 30. Residents Affected - Few Findings include: R7's medical record documents R7's diagnoses to include: Dependence on wheelchair; Diabetes Mellitus doe to underlying condition with Diabetic Autonomic Neuropathy; and Acquired Absence of Left Leg. R7's Fall Investigation (dated 02/14/24) documents R7 fell in the facility's transport van while in route to a doctor's appointment. R7's current Fall Risk Care Plan documents the following fall prevention intervention implemented on 02/14/24: Educate bus driver and resident on seatbelt safety while in wheelchair. On 04/30/24 at 01:30 PM during the group meeting, R7 stated he fell in the facility's transport van while he was being transported to a doctor's appointment. R7 stated he had pain in his right leg and was transported to a local hospital emergency room for evaluation, and then returned to the facility later that same day once he was discharged from the emergency room. On 05/02/24 at 09:35 AM, R7 was sitting in his electric wheelchair in his room going through items in drawer of a storage bin. R7 was dressed and groomed, and a full mechanical lift was in place underneath of him. R7 stated he can recall the fall he had in the facility van on 02/14/24. R7 stated he was not sitting in the usual spot he sits in the transport van due to another resident present in the van being transported to an appointment. R7 lifted up his shirt exposing his wheelchair seat belt, which was fastened. R7 stated he was not wearing his wheelchair seatbelt at the time of his 02/14/24 fall, and the transport van's lap belt that goes across his lap during transport was loose enough to allow him to slip forward out of his wheelchair when the van came to a stop. On 05/02/24 at 08:50 AM, V14 (Van Driver) entered the facility's transport van parked in front of the facility and stated the following: I had just started this job when (R7) fell in the van. I believe it was my second week. I had two residents in the van that day. They were both going to doctor's appointments. We approached a stop sign, and (R7) fell out of his wheelchair. I did not know it at the time, but he has a seatbelt on his electric wheelchair and it was not fastened. His wheelchair was secured in place, but the seatbelt in the van was not tight enough. (R7) had me loosen it before we took off that day because he said it was uncomfortable. It should have been much tighter. I know better than to allow this now. V14 then pointed to the seatbelt in the van and demonstrated how to tighten it. 145413 Page 4 of 9 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

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. Based on interview, observation and record review, the facility failed to attempt a gradual dose reduction twice in two separate quarters within the first year prescribed and document a consistent pattern of adverse behaviors for one of three residents (R38) reviewed for one of four residents (R38) reviewed for psychotropic medications in the sample of 30. Findings include: The facility's Psychotropic Medication - Gradual Dose reduction policy (revised 02/01/18) documents the following: Residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue or reduce the medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful or reduction is clinically contraindicated. The drug reaction will continue until eliminated or the clinical condition of resident worsens. R38's medical record documents R38's diagnoses to include: Major Depressive Disorder, Recurrent severe without psychotic features; Alcoholic Polyneuropathy, Insomnia, Deficiency of specified B group vitamins; Generalized Anxiety Disorder; Alcohol Dependence with Alcohol-induced persisting Amnestic Disorder; Amnesia; and Dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R38's current Physician's Orders document the following medication order: Seroquel (antipsychotic) give 50 milligrams by mouth two times a day (initial date of order 05/18/23). On 04/29/24 at 01:20 PM, R38 was sitting up in bed with the head of the bed elevated approximately 60 degrees operating his laptop. R38 was dressed and groomed, and a call light and oral fluids were within his reach. Several personal items were present in R38's room, including a large keyboard. R38 stated, I used to be a music teacher and caused some issues in my brain when I used to drink alcohol. I now am writing songs on my tablet since I am here and cannot teach anymore. R38 stated all is going well at the facility and he is currently in the process of applying for disability, Once I get disability I want to discharge and get my own place. R38 did not display any adverse behaviors during this time. R38's Monthly Behavior Monitoring Sheets (dated 11/2023 - 4/2024) document R38 is being monitored for the following target behaviors: Agitation/Anxiety/Restlessness; Verbally Aggressive. These forms document R38 displayed 5 or less episodes of these behaviors each month, except R38 displayed 7 episodes of Agitation/Anxiety/Restlessness in March 2024. On 05/01/24 at 01:20 PM, V2 (Director of Nursing) stated the following when asked what behaviors R38 displays: Loud noises will trigger and agitate (R38). V2 stated R38 is not a harm to himself of others, and the behaviors that R38 displays do not warrant the use of an antipsychotic medication. V2 confirmed R38 has been on the same dose of the antipsychotic, Seroquel, since it was initially ordered a year ago, and a gradual dose reduction has not been attempted. 145413 Page 5 of 9 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

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 interview and record review, the facility failed to conduct the required quarterly Quality Assurance meetings and failed to ensure the required Quality Assurance committee members were in attendance. These failures have the potential to affect all 63 residents currently residing in the facility. Residents Affected - Many FINDINGS INCLUDE: The facility policy, Quality Assurance and Performance Improvement Plan, dated (effective) January 02, 2024 documents, The QAPI program at (the facility) will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis and corrective action. The Quality Assessment and Assurance Committee reports to the executive leadership and Governing Body and is responsible for meeting for: Meeting, at a minimum, on a quarterly basis; more frequently, if necessary. The Quality Assessment and Assurance Committee will consist of the Medical Director/Designee, Director of Nursing Services, Administrator/Owner/Board Member/Other Leader, Infection Prevention and Control Officer, Maintenance, Business Officer Manager, Minimum Data Set Nurse, Wound Nurse, Social Services Director, Activity Director, Dietary Manager and Housekeeping Supervisor. The facility Quality Assurance Performance Improvement Meeting Minutes attendance sign-in sheets, provided by V1/Administrator include April 12, 2023 (missing Medical Director signature); February 8, 2024 and April 3, 2024 (missing Medical Director and Director of Nurses signature). No Quality Assurance Performance Improvement Meeting Minutes are available for July and October 2023 or January 2024. On 05/02/24 at 9:09 A.M., V1/Administrator verified the missing signatures for the 4/12/23 and 4/3/24 sheets. At that time, V1 also confirmed the missing sign in sheets for July 2023, October 2023 and January 2024. The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated 4/30/2024 and signed by V1/Administrator documents 63 residents currently reside in the facility. 145413 Page 6 of 9 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to utilize PPE (Personal Protective Equipment), failed to audit for appropriateness/compliance of PPE and failed to screen staff during a COVID-19 outbreak. This has the potential to affect 63 residents residing in the facility. Residents Affected - Many Findings include: The Infection Control-Interim COVID-19 policy, dated 7/24/23, PPE Use in Red & Yellow Zone Residents with Suspected or Confirmed COVID-19 Infection HCP (Health Care Providers) who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute of Occupational Health) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard. PPE including N95 should be discarded and new applied between each resident encounter, Testing of Staff and Residents: Newly identified COVID-19 positive staff or resident in a facility that can identify close contact. Test all staff regardless of vaccination status that had a higher-risk exposure with a COVID-19 positive individual. Test all residents, regardless of vaccination status that had close contact with a COVID-19 positive individual. The Infection Surveillance, Tracking and QA (Quality Assurance) Reporting policy, dated 2/14/18, Purpose: To identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: Direct observation of care and procedures performed by staff. Direct observations of adherence to hand hygiene and proper use of PPE. Monitoring the availability of PPE. The Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 3/18/24, Personal Protective Equipment HCP (Health Care Providers) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH. Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The CDC's NIOSH-Approved Particulate Filtering Facepiece Respirators this list is reviewed and updated weekly, A respirator labeled as a KN95 respirator is expected to conform to China's GB2626 standard. NIOSH does not approve KN95 products or any other respiratory protective devices certified to international standards. R317's Physician's Orders, dated 4/29/24, Follow Facility Protocol for COVID19 Screening/Precautions Droplet Precautions. On 4/29/24 at 10:06 AM, outside of R317's room posted on wall next to the door was a Droplet and Contact/Red Zone precautions signage. On 4/29/24 at 10:07 AM, V6 (Agency Certified Nursing Assistant) donned PPE and entered R317's room without tying the gown closed. V6 stated I'm Agency. This is my first rodeo here. They asked me to 145413 Page 7 of 9 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0880 come in 15 minutes early to get the door codes and had a basic quick introduction and then I got started. Level of Harm - Minimal harm or potential for actual harm On 4/29/24 at 10:10 AM, R317 was observed to leave the room with a mask on and no other PPE. R317 walked down to nurse's station and was then redirected back to R317's room by V4 (Registered Nurse). Residents Affected - Many On 4/29/24 at 10:11 AM, V4 (Registered Nurse) was observed to enter R317's room without donning PPE (N-95, goggles, gloves and/or gown). V4, sat R317 down in a chair, took disposable stethoscope and blood pressure cuff out of R317's hands and put it on the overhead table. V4 exited the R317's room and performed hand hygiene. On 4/29/24 at 10:13 AM, V4 stated, R317 wanders out in the hall all day and has to be redirect back to R317's room. On 4/30/24 at 11:55 AM, R317 was walking down B-hall with a mask donned and V10 (Registered Nurse) redirected and escorted R317 back to R317's room. R317 was observed to immediately walk out of room, past V10 and walked to the nurse's station approximately 45 ft. V9 (Registered Nurse) was observed at the Nurses Station and redirected and escorted R317 back to R317's room. At 11:58 AM, R317 walked back out into the B-hall, again walked past V10 to nurse's station where the V9 stated I Know you are hungry. Lunch is coming soon and escorted R317 back to her room. The Infection Prevention COVID positive tracking list, dated 3/1/24 through 5/1/24, documents R317 tested positive for COVID-19 on 4/23/24, R60 tested positive for COVID-19 on 4/23/24 and R63 tested positive for COVID-19 on 4/29/24. On 4/30/24 at 10:00 AM, a Droplet and Contact/Red Zone precautions sign was post outside of R63's and R60's room (directly across from one another) in B-hall. On 5/1/24 at 1:00 PM, two PPE supply cabinets in the B-hall outside of R63's room and outside of R317's room each contained 1 (one) box each with 20 (twenty) KN95 Disposable Non-Medical Face Masks Product Model: JDK-01, Jinhue Jiadaifu Medical Supplies Company. The CDC guidelines do not list KN95 Disposable Non-Medical Face Masks Product Model: JDK-01, Jinhue Jiadaifu Medical Supplies Company as NIOSH approved mask. On 5/1/24 at 2:08 PM, V13 (Agency CNA) stated If I have to go into one of those rooms (R63 and/or R60's COVID isolation rooms), I use the PPE out of that cabinet (V15 pointed at the cabinet outside of R63's room which contained the non-approved NIOSH KN95 masks.) V15 (CNA) was present and stated V15 would as well use the PPE in the cabinet. On 5/1/24 at 2:10 PM, V16 (Occupational Therapy Assistant) was observed in R63's room with the non-approved NIOSH mask donned. On 5/1/24 at 12:49 PM, V3 (Infection Control Preventionist) stated I'm going to start doing PPE audits since we have had this big outbreak. I only monitor hand hygiene compliance now. The Daily Shift Assignment form dated 4/20/24 through 4/30/24 documents the following: 10 Agency staff worked on 4/23/24; 5 agency staff on 4/26/24; 4/29/24 7 agency staff. 145413 Page 8 of 9 145413 05/02/2024 Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369

F 0880 Level of Harm - Minimal harm or potential for actual harm On 5/1/24, the Staff Source Testing binder included facility staff rapid COVID-19 testing results conducted on 4/23/24, 4/26/24 and 4/29/24. The binder lacked documentation that Agency staff were tested. On 5/1/24 at 12:35 PM, V17 (Agency Certified Nurse Aide/CNA) stated Our Agency doesn't have us test (COVID-19). No, they didn't test me here. Residents Affected - Many On 5/1/24 at 12:45 PM, V13 (Agency CNA) stated Our Agency does not require testing (COVID-19). I just got done doing the on-boarding paperwork with the DON (Director of Nursing) and nothing was said about testing. They (facility) haven't tested me. On 5/2/24 at 1:00 PM, V3 stated Agency staff are not included in source testing for COVID-19. V3 agreed without including the Agency staff in the source testing, the sampling would be skewed and not all-inclusive. 2. 4/29/24 at 12:30pm, V4, Registered Nurse, entered R60's room to pass medications. R60's has a RED ZONE sign on the door, indicating that R60 is on droplet precautions and full personal protective equipment is required. V4 had on a surgical mask, then donned a plastic face shield. V4 entered R60's and gave her the medication. V4 exited R60's room and used hand sanitizer and removed the plastic face shield. V4 continued to pass the medication on the unit. V4 verified that she did not don full PPE prior to entering R60's droplet isolation room. V4 also stated that she did not change her change her mask after leaving R60's room. The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 4/30/24, documents that 63 residents reside in the facility. 145413 Page 9 of 9