Health inspection·June 29, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to promptly act upon recommendations of the resident council group residents and failed to demonstrate the facility response to group recommendations for six residents (R10, R15, R38, R45, R56, R123) in the sample of 33. Residents Affected - Some Findings include: Facility Dietary Manager Essential duties and Responsibilities dated 3/23/17 documents: Review departmental complaints and grievances from personnel and make written reports to the Dietician and/or Administrator of action(s) taken. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. All six residents stated food served at mealtimes is not hot when served, meals were not served on time frequently served 30 minutes to 1 hour late (from the posted mealtimes), they were unaware of the facility grievance procedure and had requested short activity trips outside of the facility. R10 and R15 stated that V10, Activity Director, is the staff member who arranges and attends the Resident Council monthly meetings. During the group meeting, R15 stated they told V10, Activity Director a couple months ago they would like to have bus rides/activity trips out of the facility and never heard any response. R10 stated he has not been out of the facility in two years. On 6/27/23 at 2:40pm V11, Activity Aide stated she was told by R10, R15 and R38 that they would like to go on bus rides. V11 stated she reported the resident requests to V10 and the response from V10 was the bus is busy during the week and there's no one to drive the bus on weekends so there's no way to take residents for offsite trips. Five of six residents (R15, R38, R45, R56, R123) stated they were not offered bedtime snacks and didn't know where they were located or what was available. Resident Council Meeting Minutes dated 5/25/23 at 2pm indicates Meals are served late, some foods are hard to eat, and more shade is needed on the patio. Resident Council Meeting Minutes dated 4/27/23 at 2pm indicates Bread is dry on sandwiches and food Page 1 of 10 145437 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0565 isn't very hot. Level of Harm - Minimal harm or potential for actual harm Resident Council Meeting Minutes dated 1/26/23 at 2pm indicates Old Business: Food not hot Residents Affected - Some On 6/28/23 at 12:25pm V12, Dietary Manager stated she did not recall being told about any of the Resident Council group concerns by V10, Activity Director and she should be told if there are any dietary/kitchen concerns. On 6/29/23 at 11:45am V10 stated I just verbally tell the resident group concerns to the staff. I don't document the response or interventions. V10 stated she was aware the residents had requested bus trips I just need to reserve the van calendar a month in advance if we want to use the bus for activity trips. V10 could not provide a reason why she had not been scheduling the activity van trips. 145437 Page 2 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

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 observation, interview, and record review the facility failed to ensure all residents were informed regarding the facility Grievance process. This failure has the potential to affect all 66 residents who reside in the facility. Findings include: Facility Policy/Grievances dated/revised 9/25/17 documents: The resident has the right to voice grievances to this facility or other agency or entity that hears grievances. An Appointed Grievance Official is responsible for overseeing the grievance process. Resident Census and Conditions Report dated 6/27/23 indicates 66 residents in the facility on that date. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. All six residents stated they were unaware of the facility grievance procedure. R10 and R15 stated that V10, Activity Director, is the staff member who arranges and attends the Resident Council monthly meetings. On 6/29/23 at 11:40am V5, SSD (Social Service Director) stated she was the Grievance official and was unsure how the residents get information about the grievance process other than when they are told during admission. V5 stated she was also unaware of any posted Grievance procedure. No posted Grievance process/procedure was found throughout the facility and was confirmed as not posted by V1, Administrator on 6/29/23. 145437 Page 3 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise resident care plans for two of 20 residents (R19 and R59) reviewed for care plans in the sample of 33. Findings include: The facility's Comprehensive Care Plan Policy, revised 11/17/17, states, Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. This same policy documents that comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment. The facility's Fall/Incident Occurrence-Assessment and Documentation Guidelines, revised 1/4/16, documents after a resident fall, preventative measures are to be implemented and the resident's service plan is to be updated as indicated. The facility's Fall Prevention Program, revised 11/21/17, documents that resident Care Plans incorporate the following: each resident fall; interventions changed with each fall and preventative measures. 1. R19's Witnessed Fall Report, dated 4/13/23, states, (R19) was ambulating with therapy and fell. (R19) was sent out to the ER (Emergency Room) for an evaluation for a hematoma to the right side of her forehead and returned to the facility. Root cause is weakness. Discussed with IDT (Interdisciplinary Team) and the intervention is to allow (R19) to sit down in the wheelchair when she needs to rest. Plan of care reviewed and updated. R19's current Care Plan documents R19 is at risk for falls and that R19 had an actual fall on 4/13/23. As of 6/27/23, R19's current Care Plan did not document a new fall prevention intervention after R19's 4/13/23 fall. 2. R19's current Face sheet documents R19 with a diagnosis of Schizoaffective Disorder. R19's current Care Plan states, I use antipsychotic medications r/t (related to) Schizophrenia with an initiation date of 3/2/21. R19's Discontinue Order sheet documents an order for Olanzapine (Antipsychotic) 2.5 milligram tablet at bedtime related to Schizoaffective Disorder to be discontinued on 11/25/22. This same sheet documents the Olanzapine order was discontinued related to a Gradual Dose Reduction/GDR. R19's Psychiatry Note, dated 5/26/23, documents R19's Olanzapine medication was discontinued on 145437 Page 4 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0657 11/25/22. Level of Harm - Minimal harm or potential for actual harm As of 6/30/23, R19's current Physician Order Sheet did not document any orders for an Antipsychotic Medication. Residents Affected - Few On 6/29/23 at 11:56 AM, V1 (Administrator) verified that R19 is not currently on any antipsychotic medications and verified that R19's 4/13/23 fall intervention was not added to R19's Care Plan prior to 6/28/23 and should have been. On 6/29/23 at 1:10 PM, V3 (Assistant Director of Nursing) stated that R19's antipsychotic medication was discontinued on 11/25/22. V3 stated the medication should have been removed from R19's Care Plan but was not. 3. R59's current Care Plan documents I am a smoker. R59's current Smoking Safety Risk Assessment, dated 3/29/23, documents that R59 was admitted to the facility on [DATE] and that R59 does not currently smoke. During the survey dates of 6/27/23 through 6/29/23, R59 was not observed smoking during the Facility Smoking Breaks. On 6/29/23 at 9:13 am, V1 (Administrator/ADM) stated, (R59) has not smoked since he has been here. He cannot even get out of bed on his own, let alone smoke, and he is now on Hospice. 145437 Page 5 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

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 perform hand hygiene and follow a Physician order during skin care for one (R26) of three Residents reviewed for skin care in a sample of 33. Residents Affected - Few Findings include: Facility Dressing Change/Clean/Non-Sterile Policy, revised 1/9/18, documents: 10. remove soiled dressing and place in plastic trash bag; 11. remove soiled gloves and place in plastic trash bag; 12. wash hands, or if hand are not visibly soiled, alcohol based hand gel may be used to decontaminate the hands; 13. apply clean gloves; 16. apply prescribed ointment and/or dressing per doctor order; and secure dressing in place if needed. R26's Wound Physician's Evaluation & Management Summary, dated 6/28/23, documents a Venous Wound on R26's Right Shin (lower leg). The wound size is 5.5 centimeter/cm by 5.0 cm by 0.1 cm, with a surface area of 27.5 cm, with moderate serous exudate/drainage. R26's treatment order documents on order for medicated ointments (Leptospermum Honey and Alginate Calcium) and a Dry Dressing (Gauze Island with border) to be applied once daily for 30 days. On 6/28/23, at 11:49am, V7 (Registered Nurse) applied gloves, without hand hygiene, removed R26's soiled dressing and applied the medicated ointments (Leptospermum Honey and Alginate Calcium) to R26's Right Shin). V7 then proceeded to apply the Dry Dressing (Gauze Island with border) as V7 was disposing of the new dressing wrappers into the trash receptacle, V7's writing instrument (Magic Marker) fell into the trash receptacle. V7 then picked the writing instrument out of the trash receptacle and put it into V7's clothing pocket, then proceeded to apply the clean dressing. The Dry Dressing was not adhered and did not cover the entire venous wound and the medicated gauze dressing was exposed and not fully covered. V7 did not perform hand hygiene prior to applying gloves for the dressing change or change gloves after removing the contaminated soiled dressing. On 6/28/23, at 11:55am, V7 (Registered Nurse) stated, I am sorry, I just get so nervous, I should have changed my gloves and washed my hands. I should not have picked that marker up out of the trash can either. 145437 Page 6 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review the Facility failed to staff a Certified Dietary Manager. This failure has the potential to affect all 66 Residents residing in the Facility. Residents Affected - Many Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Position Title (Dietary Manager), created 3/23/17, documents: the Dietary Manager is responsible for partnering with the Dietician to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with current Federal, State and Local standards, guidelines and regulations governing our facility; review the departments procedure manuals and job descriptions, at least annually; and must possess a Food Service Sanitation Manager Certification. V12's (Dietary Manager) Certificate of Completion for Food Service Sanitation Manager Certification, dated 1/8/22, documents that V12 completed the online training. The Certificate of Completion also documents that This is not the Food Service Sanitation Manager Certificate. V12 stated your Food Manager Exam must be scheduled separately, and your official certificate will be issued by the Illinois Department of Public Health or the Chicago Department of Public Health upon passing the exam. On 6/29/23 at 11:28am, V12 stated, I took the Food Service course over a year ago, but I never took the exam. I am not sure why I did not take the exam. On 6/29/23, at 1:00pm, V1 (Administrator) reviewed V12's Certificate of Completion for Food Service Sanitation Manager Certification, dated 1/8/22, and stated, I never noticed that (V12) did not take the Food Manager Exam. 145437 Page 7 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. 2) Facility Policy/Snacks and House Supplements: House snacks provide additional calories and meet a resident's individualized nutritional and care plan needs. HS (bedtime) snacks should provide a minimum of a starch or bread serving and fruit drink. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. Four residents (R15, R38, R45, R56) stated they were unaware there were bedtime snacks available, did not know what snacks were supposed to be provided and were not offered bedtime snacks at any time in the evening. R10 stated sometimes staff offered snacks at night, but not always. On 6/28/23 at 12:25pm V12, Dietary Manager stated bowls of graham crackers and other crackers are placed at the nurse's station every night usually between 7 and 7:30pm. V12 stated she doesn't know what happens to them after the bowls are at the nurses station. V12 stated They should be offered to the residents.' Based on observation, interview, and record review the facility failed to serve meals at the scheduled mealtime. This failure has the potential to affect all 66 Residents residing in the facility. The facility also failed to provide bedtime snacks for five residents (R10, R15, R38, R45, R56) of six residents reviewed for bedtime snacks in the sample of 33. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Mealtimes, undated, documents Facility meal times of 7:00 am, 11:00 am and 5:00 pm. Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot. Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot. Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late. On 6/28/23, at 11:00am through 11:29am, all residents in the [NAME] Side dining room did not have a meal tray. The Facility meal cart was delivered on 6/28/23 at 11:29am and passing of the meal trays began at 11:30am. On 6/29/23, at 11:00am through 11:28am, all residents in the East Dining Room did not have a meal tray. On 6/29/23, at 11:00am through 11:41am, all Residents in the [NAME] Dining Room did not have a meal tray. The East Dining Room meal cart was delivered to the East Dining Room at 11:28am and the 145437 Page 8 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0809 [NAME] Hall Dining Room meal cart was delivered at 11:41am. Level of Harm - Minimal harm or potential for actual harm On 6/28/23, at 10:00am, during the Resident Council Meeting, R10, R15, R28, R45, R56 and R123 verified that mealtimes are not served as posted and that meals are served a half-hour to an hour late, also making the food cold. Residents Affected - Many On 6/28/23, at 12:18pm, V12 (Dietary Manager) stated, We do not start serving the main dining rooms until after we serve our Dementia Unit. Our scheduled lunch mealtime is 11:00 am, but we do not usually get the carts out until close to 11:30 am. On 6/29/23, at 11:50am, V12 (Dietary Manager) stated, I had a staffing issue today, so that is why the lunch meal was late. 145437 Page 9 of 10 145437 06/29/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to maintain required safe serving/holding food temperatures for Resident meals. This failure has the potential to affect all 66 Residents residing in the facility. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Serving Temperatures for Hot and Cold Foods Policy, dated 2020, documents: food will be served at the following temperatures to ensure a safe and appetizing dining experience; and required meat and vegetable temperatures of 135 degrees Fahrenheit to 170 degrees Fahrenheit. Facility Mealtimes, undated, documents Facility mealtimes of 7:00am, 11:00am and 5:00pm. Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot. Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot. Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late. On 6/27/23, at 11:40am, the meatloaf temperature was 102 degrees (Fahrenheit) and the sliced carrots were 120 degrees (Fahrenheit). On 6/28/23, at 10:00am, during the Resident Council Meeting, R10, R15, R28, R45, R56 and R123 verified that mealtimes are not served as posted and that meals are served a half-hour to an hour late and are often cold. On 6/28/23, at 12:18pm, V12 (Dietary Manager) stated, I do not know why the meatloaf and carrots were that cold, I did not even notice the low temperature. I know we have had prior complaints about the cold food temperature. 145437 Page 10 of 10