Health inspection·September 20, 2023

F 0610 Respond appropriately to all alleged violations. 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 investigate an allegation of a potential misappropriation of resident property for one (R9) of three residents reviewed for criminal activity in a sample of three. Residents Affected - Few Findings include: The facility's Abuse Prevention and Reporting - Illinois policy, revised 10/24/22, documents Internal Reporting Requirements and Identification of Allegations: Supervisors shall immediately inform the administrator of person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. R9's current clinical record, documents R9 as moderately cognitively impaired with diagnoses including Unspecified Dementia, moderate, with Agitation. R9's Criminal History Record, dated 1/16/23, documents R9 is a Registered Identified Sex Offender and was convicted for indecent liberty of a child in 1979 and 1980. On 9/19/23, at 12:03pm, R9 was lying in bed with a personal computer located on a desk against the wall across from the entrance to R9's room. At this time R9 stated he does use the WIFI for Internet on his personal computer and that there's porn on there, but you don't have to stay on it. You can skip on by it, ya know? On 9/19/23, at 2:27pm, V1 stated the following: A nurse (V9 Registered Nurse/RN) called me a week ago and said (V21 Certified Nursing Assistant/CNA) reported to (V9) that (V21) suspected (R9) was on a porn site. I asked (V9) if she saw it and (V9) did not. I did not talk to (V21 CNA). At this time, V1 denied doing any investigation for this allegation and was unable to provide any investigation documents. On 9/19/23, at 2:57pm, V21 CNA, stated that V21 walked into R9's room where loud music was playing and saw R9 on his computer viewing young Chinese girls aged 10 to [AGE] years old whose dresses were blowing up exposing their underwear. Each time they put a microphone up to their mouths their dress would fly up. What got me was the phone numbers going across the back. V21 stated she reported this to V9 Registered Nurse/RN but is not sure if anything was done. V21 stated that no one from the facility has asked her anything about this occurrence. Page 1 of 5 145437 145437 09/20/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0610 Level of Harm - Minimal harm or potential for actual harm On 9/19/23, at 3:32pm, V9 RN stated the following: (V21 CNA) told me that (R9) was watching young girls on porn called 'Chinese Virgins'. I didn't see it. V9 continued to state that (V21) said the Chinese girls looked young but (V21) didn't give me an age. (V21) said the computer screen was flashing Chinese Virgins, across the screen. (V21) wasn't explicit in detail, but said it was porn. I reported it to (V1) and have not heard any feedback since. Residents Affected - Few 145437 Page 2 of 5 145437 09/20/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2) Current Physician order Summary Report indicates R1 has diagnoses that include Unspecified Dementia, Alzheimer's Dementia with Early Onset and Severe Dementia in other diseases with behavioral disturbance. Current Comprehensive Assessment indicates R1 was identified as having wandering behaviors, occurring daily, and intruding on the privacy of others. On 9/14/23 at 10:20am V5 and V6, CNA's identified R1 as a wanderer with behavior of wandering into to other resident rooms and getting into their beds. V5 stated that R1 is difficult to redirect at times and will shake her fist at staff. Progress Note dated 6/26/23 at 10:12am indicates R1 has chronic wandering behaviors. Progress Note dated 6/27/23 at 8:20am indicates During morning medication pass, (R1) observed laying in another resident bed under the covers watching television. Progress Note dated 7/7/23 at 7:04pm indicates (R1) observed in another residents room sleeping on bed. Note indicates staff are following care plan. Current Care Plan indicates only Behavior Management as focus area. Care Plan does not identify wandering as a target behavior and does not identify interventions to address R1's wandering into other residents' rooms and getting into other resident's beds. Based on observation, interview, and record review the facility failed to develop interventions to address wandering on resident Care Plans for two (R1 and R2) of three reviewed for care plans. Findings include: 1. On 9/14/23, between 9:30am and 10:00am, R2 independently ambulated around the locked unit. R2's current Physician Order Sheet/POS documents R2 has diagnoses including Dementia. R2's Minimum Data Set/MDS assessment, dated 8/29/23, documents R2 is severely cognitively impaired. On 9/14/23, at 10:20am, V5 and V6 Certified Nursing Assistants/CNAs identified R2 as one of the wandering residents in the locked unit. R2's current Care Plan does not include any focus or interventions for wandering. On 9/14/23, at 3:37pm, V13 Social Service Director confirmed R1 and R2 are wandering residents who should have had wandering addressed on their care plans. 145437 Page 3 of 5 145437 09/20/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Current Physician Order Summary Report indicates R1 has diagnoses that include Unspecified Dementia, Alzheimer's Dementia with Early Onset and Severe Dementia in other diseases with Behavioral Disturbance. Current Comprehensive Assessment indicates R1 was identified as having wandering behaviors, occurring daily, and intruding on the privacy of others. Current Social Service Elopement Risk and Community Survival Skills assessment dated [DATE] indicates R1 is at risk to elope and should be placed on the Elopement Risk Protocol and Care Plan for Elopement is indicated. Current Care Plan indicates only Behavior Management as focus area. Care Plan does not identify R1 as an elopement risk and does not identify interventions to address R1's risk of elopement. List of residents identified as Elopement Risk included in the Elopement binder at the nurse's station does not include R1. On 9/14/23 at 3:37pm V13, Social Service Director stated R1 should have been included in the Elopement Risk Protocol including being identified on the list of residents identified as Elopement risks and a care plan should have been developed to address managing and monitoring R1's Elopement Risk. Based on observation, interview, and record review, the facility failed to complete Elopement Risk assessment, failed to include two residents identified as at risk for Elopement in the Elopement Risk Protocol and in the facility's Elopement risk binder for two residents (R1 and R2) Findings include: The facility's Identification of Elopement Risk policy, undated, documents Policy Statement: To identify residents that are at risk for elopement. Policy Interpretation and Implementation: 1. Residents will be evaluated for elopement risk on admission and quarterly. 2. The resident's service plan will be modified to indicate the resident is at risk for elopement episodes, if applicable. 3. Interventions to prevent elopement will be entered into the resident's service plan. 1. On 9/14/23, between 9:30am and 9:40am, R2 independently ambulated around the locked unit and then hovered around the exit door of the locked unit. R2's current Physician Order Sheet/POS documents R2 has diagnoses including Dementia. R2's Minimum Data Set/MDS assessment, dated 8/29/23, documents R2 is severely cognitively impaired. R2's Elopement Risk & Community Survival Skill Assessment, dated 8/25/23 and signed by V14 Social Service Director/SSD, is incomplete. The facility's Elopement binder, located at the nurse's station, does not include R2 on the list of residents identified as Elopement risk. 145437 Page 4 of 5 145437 09/20/2023 Goldwater Care Princeton 515 Bureau Valley Parkway Princeton, IL 61356

F 0689 Level of Harm - Minimal harm or potential for actual harm On 9/14/23, at 3:37pm, V13 SSD stated V14 did not complete R2's elopement risk assessment even after receiving further information including R2's diagnosis of Dementia. R2 confirmed that R2 should have been placed on the Elopement Risk Protocol and on the list of residents at risk for elopement in the elopement binder. Residents Affected - Few 145437 Page 5 of 5