Inspection·June 15, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm On 6/15/23 V9 (Laundry Supervisor) stated (V11/R1's family member) has provided me a list of missing clothing items with pictures and I am currently searching for missing items. We do not have an admission inventory list so I have no idea if all of these clothes were actually here, I don't remember seeing some of them, but (V11) does (R1)'s laundry so it may just be that I haven't seen them. None of these clothes are in the laundry department or in any other resident's rooms. I have checked. Residents Affected - Many R1's Medical Record does not include a record or list of items brought in upon admission. On 6/14/23 at 11:00 AM R2 stated Laundry is a mess around here, things go missing for weeks. They eventually show back up. R2's Medical Record does not include a record or list of items brought in upon admission. On 6/14/23 at 11:30 AM R3 stated I watch my clothes very carefully because the laundry department does not pay attention. I don't let them leave stuff in here that is not mine. R3's Medical Record does not include a record or list of items brought in upon admission. On 6/15/23 at 9:15 AM R4 stated I stay on them (staff) about my stuff. The laundry department is a joke. It is like a black hole; stuff goes in but never comes back out. I think I have everything now, I keep track. R4's Medical Record does not include a record or list of items brought in upon admission. On 6/15/23 at 12:00 PM V1 (Administrator) stated Every resident should have an inventory done by the admitting staff and it should be updated when the resident or the family brings in anything else. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145437 If continuation sheet Page 2 of 8 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 145437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview the facility failed to address personal grievances and concerns voiced at monthly resident council meeting minutes. This failure has the ability to affect all 68 residents who currently reside in the facility. Findings Include: The Facility's Grievances policy dated 11/28/2012 documents the purpose of the policy is to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at the campus. Grievances may be filed orally (meaning spoken), in writing, or anonymously. All written grievances shall include: the date the grievance was received; a summary statement of the grievance; department assigned to investigate; steps taken to investigate the grievance; summary of the pertinent findings or conclusions regarding the concern(s).; statement as to whether the grievance was confirmed or not confirmed; corrective action taken by the facility as a result of the grievance, including measures taken to prevent further potential violations of any resident right while the alleged violation is being investigated and the date the written decision was issued to the resident or the complainant. The Facility's undated Purpose and Function of Resident Council Memo documents The Activity Director (or other designee) is available to be in attendance to serve as a liaison between residents and administration and to denitrify simple issues as they arise when invited. According to the Department of Public Health regulations, the council serves to: 1. Obtain and disseminate information; 2. Submit and adopt recommendations for facility programming and improvements.; 3. Identify problems quickly and efficiently; 4. Recommend an orderly resolution of problems. R1's Concern/Grievance Form dated 4/14/23 documents V11 (R1's Health Care Power of Attorney) concern was: Not getting calls back regarding updates-PT (Physical Therapy) and Nursing. Laundry missing. R1's Concern/Grievance Form documents Update from PT and nursing given and laundry notified of missing clothes, family does laundry signs hung up in room. On 6/15/23 at 10:00 AM V1 (Administrator) stated I know therapy called her, but I don't know when or what the concern was. I called her and gave her a nursing update; I did not document any of our conversation. Laundry notified of missing clothes does not answer where the clothes are. R5's Concern/Grievance Form dated 3/7/23 documents R5's concern as Not getting showers or PT (Physical Therapy). R5's Concern/Grievance Form documents Spoke with nursing staff. On 6/15/23 at 10:00 AM V1 (Administrator) stated she Did not know which nursing staff were spoken to, why the resident was not getting their showers or any other information regarding the grievance. R6's Concern/Grievance Form dated 5/4/23 documents R6's concern as Resident stating she is not receiving showers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145437 If continuation sheet Page 3 of 8 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 145437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R6's Concern/Grievance Form documents SSD (Social Service Director) and CNA Scheduler had a conversation as well as spoke with resident. Offered to move shower time she wants to stay on days for showers. On 6/15/23 at 10:00 AM V1 (Administrator) stated I don't know what that answer means. I don't know who was not giving the resident her shower or anything else about it. The Social Service Director was terminated for not doing her job, this would be a good example of that. The Resident Council Meeting Minutes dated 12/29/22 documents Nursing: Sometimes have to wait for lights to be answered. and Dietary: Food sometimes not hot. The Resident Council Meeting Minutes dated 1/26/23 documents Nursing: some feel it takes too long to answer lights and Dietary: Don't always get the dessert that is on the menu. The Resident Council Meeting Minutes dated 2/23/23 documents Nursing: Some residents not getting showers and Laundry/Housekeeping: Missing clothes and Dietary: Veggies are hard and not enough alternative options. The Resident Council Meeting Minutes dated 3/30/23 documents Nursing: Slow answering lights. The Resident Council Meeting Minutes dated 4/27/23 documents Dietary: Bread is dry on sandwiches; food isn't very hot. The Resident Council Meeting Minutes dated 5/25/23 documents Dietary: Meals served late; some food too hard to eat. On 6/14/23 V4 (Activity Director) stated I don't keep attendance or track any of the complaints that are brought up in Resident Council Meetings, I tell the appropriate Department Head and assume that the problem is going to be dealt with. I do realize that there are repeat complaints about call lights and dietary issues, I did not follow up with anyone to check if these concerns were being addressed. The Resident Roster dated 6/14/23 lists 68 residents who currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145437 If continuation sheet Page 4 of 8 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 145437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to recognize an allegation of possible neglect for one resident (R4) of four residents reviewed for abuse. Residents Affected - Few Findings Include: The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 defines neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish (42 CFR 483.5) Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident (20 1 ILCS 45/1-117) including deprivation of goods and services by staff. Neglect may be the result of a pattern of failures or the result of one or more failures involving one resident and one staff person. On 6/15/23 at 9:00 AM R4 stated On Tuesday 6/6/23 I asked (V10/CNA) to change my brief. (V10) stated there is no reason for you to not be able to make it to the bathroom, so I am not going to be changing someone who just sits and messes themselves. I felt humiliated, I cannot help it. I can transfer myself to the toilet, but sometimes when I get there, I have already been incontinent, and I want to make sure that I get clean. Ever since last Tuesday, (V10) just ignores me, he literally behaves as if I don't exist. If my call light is on, he comes in here and chats all friendly with my roommate and helps him with whatever but never asks me what I need and then he leaves. A couple of days ago, he did not tell me that the lunch trays were here so by the time I got up and got to the table my lunch was cold. I don't know why (V10) hates me; I don't want him to take care of me anymore. I have talked to the nurses and CNAs about it, it doesn't help. He was assigned to my hallway last night (6/14/23) which means I couldn't ask for anything. I feel so alone and isolated when he is here. On 6/15/23 at 9:05 AM V8 (CNA) confirmed that R4 had told her his concerns regarding V10. V8 stated (R4) always complains about someone, (V10) would never ignore a resident. I told (V7/Social Services Director) about it. On 6/15/23 at 9:10 AM V7 (Social Service Director) stated that (V8/CNA) had told her that (R4) complained that (V10) would not help him when requested. V7 stated I wanted to get a little more background on (R4) first, it sounds like he complains all the time. V7 stated (V10/CNA) has worked here for years, I doubt he would do something like that. On 6/15/23 at 9:30 AM V2 (Director of Nursing) stated Yes, I spoke with (V10/CNA) last night (6/14/23) at the beginning of his shift, (V10) asked me if he had to change (R4) because he felt that (R4) could do it himself. I told him yes that whether or not he feels like the resident can do more, if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145437 If continuation sheet Page 5 of 8 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 145437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356 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 0607 the resident requests assistance (V10) was required to give it. Level of Harm - Minimal harm or potential for actual harm On 6/15/23 at 9:45 AM V1 (Administrator) stated (V2/Director of Nursing) told me that she spoke with (V10/CNA) because (V10) felt that (R4) could assist himself more than he does, and I told her I agreed with her that (R4) should be changed anytime he asks. No one used the word neglect though, so I didn't really think about that being abuse. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145437 If continuation sheet Page 6 of 8 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 145437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to protect one resident (R4) after a complaint of neglect of four residents reviewed for abuse. This failure caused R4 stress, anxiety and feelings of isolation. Residents Affected - Few Findings Include: The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 defines neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish (42 CFR 483.5) Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident (20 1 ILCS 45/1-117) including deprivation of goods and services by staff. Neglect may be the result of a pattern of failures or the result of one or more failures involving one resident and one staff person. The Facility's Abuse Prevention and Reporting-Illinois policy dated 11/28/16 documents The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated. On 6/15/23 at 9:00 AM R4 stated On Tuesday 6/6/23 I asked (V10/CNA) to change my brief. (V10) said there is no reason for you to not be able to make it to the bathroom, so I am not going to be changing someone who just sits and messes themselves. I felt humiliated, I cannot help it. I can transfer myself to the toilet, but sometimes when I get there, I have already been incontinent, and I want to make sure that I get clean. Ever since last Tuesday, (V10) just ignores me, he literally behaves as if I don't exist. If my call light is on, he comes in here and chats all friendly with my roommate and helps him with whatever but never asks me what I need and then he leaves. A couple of days ago, he did not tell me that the lunch trays were here so by the time I got up and got to the table my lunch was cold. I don't know why (V10) hates me; I don't want him to take care of me anymore. I have talked to the nurses and CNAs about it, it doesn't help. He was assigned to my hallway last night (6/14/23) which means I couldn't ask for anything. I feel so alone and isolated when he is here. On 6/15/23 at 9:05 AM V8 (CNA) confirmed that R4 had told her his concerns regarding V10. V8 stated (R4) always complains about someone, (V10) would never ignore a resident. I told (V7/Social Services Director) about it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145437 If continuation sheet Page 7 of 8 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 145437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/15/23 at 9:10 AM V7 (Social Service Director) stated that (V8/CNA) told her that (R4) complained that (V10) would not help him when requested. V7 stated I wanted to get a little more background on (R4) first, it sounds like he complains all the time. V7 (V10/CNA) has worked here for years, I doubt he would do something like that. V7 confirmed that V10 (CNA) worked on 6/14/23 and was assigned to R4. On 6/15/23 at 9:30 AM V2 (Director of Nursing) stated Yes, I spoke with (V10/CNA) last night (6/14/23) at the beginning of his shift, (V10) asked me if he had to change (R4) because he felt that (R4) could do it himself. I told him yes that whether or not he feels like the resident can do more, if the resident requests assistance (V10) was required to give it. V2 confirmed that V10 (CNA) worked on 6/14/23 and was assigned to R4 On 6/15/23 at 9:45 AM V1 (Administrator) stated (V2/Director of Nursing) told me that she spoke with (V10/CNA) because (V10) felt that (R4) could assist himself more than he does, and I told her I agreed with her that (R4) should be changed anytime he asks. No one used the word neglect though, so I didn't really think about that being abuse. V1 confirmed that V10 (CNA) worked on 6/14/23 and was assigned to R4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145437 If continuation sheet Page 8 of 8