Health inspection·April 10, 2023

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 employ a dietary manager on a full-time basis, and ensure all dietary staff withheld a food handler's certification. This has the potential to affect all 75 residents residing within the facility. Findings include: The facility's Dietary Manager job description, dated 3/23/17, documents, The Dietary Manager is responsible for partnering with the Dietitian 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, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary Department is maintained in a clean, safe, and sanitary manner. Qualifications: Must possess, as a minimum, a high school diploma. Must possess a Food Service Sanitation Manager Certification in the State of Illinois. Must have, as a minimum three years' experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility. Must be knowledgeable of dietary practices and procedures as well as the laws, regulations, and guidelines governing dietary functions in nursing care facilities. The facility's Dietary Aide job description, dated 5/2/17, documents, The Dietary Aide is responsible for providing assistance in all food functions as directed/instructed and in accordance with established food policies and procedures. On 04/03/23 at 10:20 AM, V6 (Cook) stated, We don't have a dietary manager right now. On 04/03/23 at 02:14 PM, V7 (dietary aide) was cleaning off plates and wiping down the dining room tables with a bucket of sanitizer. V7 stated, What do you mean check sanitizer level. I used the hose of sanitizer on the wall and filled up the bucket and added some dish soap. I don't check any kind of levels. V8 (dietary aide) handed V7 the sanitizer test strips, and V7 stated, How do I do this? V7 dipped the test strip in the sanitizer bucket and removed it. The test strip read zero. V7 stated, It's orange like the zero on the container. What's that mean? What is it supposed to be? The orange on this container says zero. On 04/05/23 at 11:45 AM, V20 (cook), stated, We do not have a (dietary) manager right now. On 04/05/23 at 11:08 AM, V1 (Administrator) stated, We do not have a dietary manager at this time. She quit. A list of the dietary employees, provided on 4/5/23 at 12:30 p.m. by V10 (Human Resources), documents that V7 is a dietary aide that was hired on 5/24/22, and V11 is a dietary aide who was hired on 4/25/22. V10 also provided all the dietary staff's food handler certifications. There is no documentation of V7 and V11 having a food handler certification. V10 confirmed that she had provided all the food handler certifications. On 4/5/23 at 1:44 p.m., V2 (Director of Nursing) stated, The kitchen doesn't have a dietary manager. This could be part of the kitchen issues that they don't have a supervisor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 2 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 0801 Level of Harm - Minimal harm or potential for actual harm The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 4/3/23 and signed by V14 (Minimum Data Set Coordinator/Licensed Practical Nurse), documents that 75 residents reside in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 3 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to serve pureed food according to the facility's menu for three of three residents (R4, R28, R31) reviewed for pureed diets in the sample of 40. Residents Affected - Few Findings include: The facility's Pureed Food Preparation policy dated 2020, documents, Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value. Each menu cycle will be reviewed to ensure there is a pureed recipe for each item to be served. The facility's Diet Spreadsheet Week 3, dated Fall/Winter 2022, documents that the pureed menu for 4/3/23 was to include pureed applesauce cake. On 04/03/23 at 01:10 PM, V6 (Cook) and V8 (Dietary Aide) were plating up the lunch pureed meals. No pureed cake was placed on the tray. V8 stated, We didn't have enough cake. So, the pureed residents are getting applesauce instead. The facility Diet Type Report, dated 4/5/23, documents that R4, R28, and R31 are pureed diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 4 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 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 serve food at an appropriate temperature to prevent pathogenic microorganisms that may cause foodborne illness, maintain safe food temperatures of food being held on the steam table, monitor food temperatures, use a sanitizing solution to sanitize the high contact surfaces of the kitchen and dining room tables, monitor the sanitizer levels prior to cleaning surfaces, and maintain clean air vents in the kitchen. This has the potential to affect all 75 residents residing in the facility. Findings include: The facility's Monitoring Food Temperatures for Meal Service, dated 2020, documents, Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. The temperature for each food item will be recorded on the Food Temperature log. Foods that required a corrective action (such as reheating); will have the new temperature recorded with a notation of the corrective action intervention. If the serving/holding temperature of a hot food item is not at 135 degrees F or higher when checked prior to meal service, the item will be reheated to at least 165 degrees F for a minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within two hours. The facility's Refrigerator and Freezer Temperatures, dated 2020, documents, To ensure all perishable foods stay fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators located in nourishment rooms. Dining services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift. Corrective actions are taken as necessary to insure only safely stored foods are served to residents. Each refrigeration and freezer unit in the main kitchen is checked at department opening and before any food product is used for the day. The employee ensures that all cold storage units are 41 degrees F (Fahrenheit) or below for refrigeration or 0 degrees F or below for freezers. Temperatures are taken from the thermometer located inside the unit. The facility's Sanitizing and Disinfectant Solutions policy, dated 2020, documents, The employee will prepare sanitizer solution or disinfectant solution in accordance with manufacture guidelines. If a dispensing system is used, appropriate concentration level will be tested at least daily. Sanitizing solutions are changed in accordance with manufacturer instructions or when they become visibly soiled. In general, each shift should prepare fresh solutions. A test tape/paper should be used to verify the concentration. The facility's Quat Sanitizer Concentrate label, provided by V1 (Administrator) on 4/5/23, documents, 150-400 ppm (parts per million) Quat Range. EPA-registered sanitizer for pre-cleaned use on hard, non-porous prep surfaces and ware, kills foodborne organisms. Three compartment sink sanitizer. Food contact surface sanitizer. Sanitation Range Testing: Testing solution should be between 150-400 ppm. The facility's Dishwashing: Machine Operation policy, dated 2020, documents, The Dining Services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 5 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in preparation and service of food. The facility's Cleaning Rotation, policy, dated 2020, documents, Equipment and utensils will be cleaned and sanitized according to the following guidelines, or manufacturer's instructions. Resource: Monthly Cleaning Schedule-Clean ceilings (annually or as needed). The facility's Sanitizer Test Strip Log dated 3/2023 and provided on 4/3/23 at 10:41 a.m. by V6 (Cook), documents, Employees will record the reading once a day and record corrective action, if taken. The person in charge or his/her designee will verify that employees use the appropriate test strips for the sanitizing solution bucket and will review the log at the conclusion of each month. The log documents that the sanitizer is checked at 6 a.m., 10 a.m., 2 p.m., 4:30 p.m., 6:30 p.m., and bucket. The log has no documentation of any testing being completed on 33 designated times. V6 stated, This is the log we use for the dishwasher. We do not have a log for the three-compartment sink or the sanitizer buckets. V6 confirmed the lack of documentation. The facility's Sanitizer Test Strip Log, dated 4/2023, has no documentation of any sanitizer levels being checked on 4/2-4/3/23. The facility's Food Temperature Chart dated 3/5-3/11/23, documents that no food temperatures were obtained on three of the 21 meals. The facility's Food Temperature Chart dated 3/12-3/18/23, documents that no food temperatures were obtained on six of the 21 meals. The facility's Food Temperature Chart dated 3/26-4/1/23, documents that no food temperatures were obtained on 3/26/23 at dinner. The facility's Food Temperature Chart dated 4/2-4/8/23 and provided on 4/3/23 at 10:41 a.m. by V6 (Cook), documents that no food temperatures were obtained on 4/2 breakfast, lunch, and dinner, and 4/3 breakfast. The facility's Temperature Log-Milk Cooler, dated 4/23 and provided by V6 on 4/3/23 at 10:41 a.m., has no documentation of temperatures being obtained on 4/2/23. The facility's Temperature Log-Milk Cooler, dated 3/23, has no documentation of temperatures being obtained on 15 of the 62 indicated times. The facility's Resource: Refrigerator/Freezer Temperature Log-Refrigerator, dated 3/23, has no documentation of temperatures being obtained on 11 of the 62 indicated times. The facility's Resource: Refrigerator/Freezer Temperature Log-Refrigerator, dated 4/23 and provided by V6 on 4/3/23 at 10:41 a.m., has no documentation of temperatures being obtained on 4/2/23. The facility's Resource: Refrigerator/Freezer Temperature Log-Freezer, dated 3/23, has no documentation of temperatures being obtained on 13 of the 62 indicated times. The facility's Resource: Refrigerator/Freezer Temperature Log-Freezer, dated 4/23 and provided by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 6 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 0812 V6 on 4/3/23 at 10:41 a.m., has no documentation of temperatures being obtained on 4/2/23. Level of Harm - Minimal harm or potential for actual harm On 4/03/23 at 10:36 AM, the three-compartment sink contained a brown tub filled with water that contained silverware, and two red buckets with towels in them. V6 (Cook) stated, We use the three-compartment sink for our silverware and our sanitizing buckets that we use for cleaning the tables. We place the silverware in the tub before it goes through the dishwasher. We do not have a log tracking the sanitation of the sink. Using a test strip, V6 tested the tub of silverware, and it registered zero. Then, V6 tested both sanitizing buckets and both buckets tested zero. V6 confirmed that they all registered zero. V8 (Dietary Aide) placed a bucket in the sink and using the sanitizer hose filled the bucket. The liquid in the hose was clear as well as the water. V8 tested the liquid in the bucket and it registered zero. V8 stated, The buckets in the sink are new buckets for here in the kitchen. I dumped the buckets I used to clean the resident tables after breakfast. I didn't check the level of sanitizer before I cleaned the tables. I never do. We don't have a log for it either. Ever since the dishwasher was worked on, I've been telling them something was wrong with this sink. It's been about a month now. Residents Affected - Many On 04/03/23 at 11:50 AM, V7 (Dietary Aide) was washing dishes in the dishwasher and stated, I don't check anything on the dishwasher. On 04/03/23 at 11:53 AM, an air conditioner vent that was covered with a brown fuzzy substance in the ceiling was blowing directly over uncovered cake on a cart to be served for lunch. An air conditioner vent that was covered with a brown fuzzy substance in the ceiling was blowing directly over cook prep area next to the stove. An air conditioner vent that was covered with a brown fuzzy substance in the ceiling was blowing directly over the oven area. An air conditioner vent that was covered with a brown fuzzy substance in the ceiling was blowing directly over the steam table. V6 stated We have a cleaning scheduled for the ceilings. I thought they were done like a week ago. On 04/03/23 at 12:00 PM, the food steam table contained mashed potatoes, turkey, spinach, gravy, green beans, mechanical soft turkey, pureed green beans, and pureed turkey. V6 performed temperature checks on all the food. The food temperatures were: mechanical soft turkey 115 degrees F. (Fahrenheit), pureed green beans 100 degrees F, and pureed turkey 95 degrees F. V6 stated, The proper holding temperature is 125 degrees F. On 04/03/23 at 12:15 PM, V6 removed the steam table covers and began the meal serving process. On 04/03/23 at 12:18 PM, V6 prepared a plate with mechanical soft turkey, mashed potatoes, spinach, and a roll. V6 placed the plate on tray in the serving window for staff to deliver to the resident. This surveyor stopped V6 from allowing staff to deliver the meal due to the unsafe temperature. On 04/03/23 at 02:14 PM, V7 was cleaning off plates and wiping down the dining room tables with a bucket of sanitizer. V7 stated, What do you mean check sanitizer level. I used the hose of sanitizer on the wall and filled up the bucket and added some dish soap. I don't check any kind of levels. V8 handed V7 the sanitizer test strips, and V7 stated, How do I do this? V7 dipped the test strip in the sanitizer bucket and removed it. The test strip read zero. V7 stated, Its orange like the zero on the container. What's that mean? What is it supposed to be? The orange on this container says zero. On 04/04/23 at 09:45 AM, V9 (Dietary Aide) was washing dishes in the dishwasher. V9 stated, I don't test the sanitizer levels. I only work two days a week, so I don't know what to do. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 7 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 04/05/23 at 11:45 AM, V20 (cook), stated, We do not have a manager right now. Food temperatures are done when the food is pulled out and when it's ready to be served on the steam table. We document the holding temperature, but not the cooked temperature. The minimum holding temperature is 145 or 150. If it's below that they should get rid of it and find something else to make. The cook on duty is responsible for checking freezer/refrigerator temperatures. Whoever fills the sanitizer bucket or sink is responsible for checking. One bucket is for kitchen to clean off counter tops, one is for the sink, and one is for dining room. The solution should be between 50-100. They should be documenting it. I know I do. On 04/05/23 at 11:08 AM, V1 (Administrator) stated, We do not have a dietary manager at this time. On 4/5/23 at 1:44 p.m., V2 (Director of Nursing) stated, The sanitizer the kitchen staff use on the tables and in the kitchen is used to kill COVID-19. These are high contact surfaces, and if there is no sanitizer in the mixture, that could contribute to the spread of COVID-19. The kitchen doesn't have a dietary manager. This could be part of the kitchen issues that they don't have a supervisor. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 4/3/23 and signed by V14 (Minimum Data Set Coordinator Licensed Practical Nurse), documents that 75 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 8 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 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 wear appropriate PPE (Personal Protective Equipment) while in COVID-19 positive resident rooms, failed to remove/disinfect contaminated PPE upon exit from COVID-19 positive resident rooms and prior to traveling throughout the facility for one resident (R71) and failed to wear proper PPE while handling COVID-19 positive resident laundry during laundry services, during a facility-wide COVID-19 outbreak. The facility also failed to apply the required PPE prior to resident COVID-19 testing and perform hand hygiene after removing gloves for three residents (R26, R64, R67). These failures have the potential to affect all 75 residents currently residing in the facility. Residents Affected - Many Findings include: The facility policy, Interim COVID-19 policy, dated (revised) 10/31/2022 directs staff, If entering a Red Zone under COVID-19 transmission- based precautions, staff must wear full PPE, including N95 respirator, eye protection, gown and gloves. PPE including N95 should be discarded and new applied between each resident encounter. Non-disposable eye protection should be sanitized between each resident in yellow or red zone; if disposable eye protection is used, may sanitize or dispose of the eye protection and apply new. 1.) R71's Nursing Progress Notes, dated 4/3/2023 at 8:52 A.M. document, Social Service attempted to contact (R71)'s spouse to inform her that (R71)'s recent COVID test came back positive. Will continue to monitor. R71's COVID-19 (facility) Test Result, dated 3/31/23 documents, Positive for COVID-19. On 4/3/23 at 11:00 A.M., a red sign posted on R71's door documents, Red Zone: droplet and contact precautions. Hand hygiene prior to entrance. Ask resident to apply surgical mask when staff in room. Wear full PPE (Personal Protective equipment) including N-95 face mask, dispose of afterwards; Goggles, sanitize upon exit from room; Gloves, remove upon exit from room and sanitize hands; Gown, remove upon exit from room. On 4/3/23 at 11:14 A.M., V12/Registered Nurse/RN was preparing to administer medications for R71. V12/RN entered R71's room without performing hand hygiene, wearing only a surgical mask and prescription eyeglasses. V12/RN did not don gloves, a gown or the appropriate face mask or eye protection. Upon exiting room, V12/RN did not change her contaminated mask nor cleanse her contaminated eyeglasses. V12/RN then entered the facility Main Dining Room, where the facility residents were gathered for the noon meal, to continue passing medications. On 04/3/23 at 1:32 P.M., V13/Certified Nursing Assistant (CNA) entered (R71's) room to pass a noon meal tray. V13/CNA entered R71's room wearing a surgical mask, goggles, and gloves. V13/CNA did not perform hand hygiene prior to applying gloves. V13/CNA entered R71's room without donning a gown or an N-95 mask. Upon exit from (R71)'s room, V13/CNA did not change her contaminated mask or cleanse her contaminated eye goggles. V13/CNA then returned to the facility Main Dining Room where the facility residents were seated, eating the noon meal. On 4/5/23 at 8:15 A.M., V2/Director of Nurses (DON) confirmed that when a resident is in isolation for COVID-19, staff are expected to perform hand hygiene prior to applying gloves and upon removing them, apply a gown and an N-95 mask and remove them upon exit and wear eye protection and cleanse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 9 of 10 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 145486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Spring Valley 1300 North Greenwood Street Spring Valley, IL 61362 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 0880 the eye protection upon exit from the isolation room. Level of Harm - Minimal harm or potential for actual harm 2.) On 04/03/23 at 10:43 AM, V4/Laundry was hanging up clean laundry in the hallway on a cart. V4 walked into the laundry room with soiled laundry barrels immediately to the right. Three clear bags of laundry were sitting on the floor. V4 stated, The soiled laundry from the isolation rooms are in those clear bags on the floor. When I'm handling all of the soiled laundry, I wear my gloves, surgical mask, and my face shield. I think I should be using a gown, and I've asked for one. They always tell me I don't need them. Just this morning, I pulled a urine-soaked blanket, and it was laying on my arms. It's gross. V4 demonstrated the washing cycles for the washing machines that were across from the soiled linen bins. Directly to the left of the soiled bins, a table was against the wall with a bin directly touching the table. V4 stated, That is where we fold the clean laundry. Then, when I'm done, I go back out the same door we come in. We go by the soiled linen bins as well. I had COVID and just came back to work. I was off for 10 days with no symptoms luckily. Residents Affected - Many On 04/04/23 at 09:41 AM, V5/Laundry/Housekeeping Supervisor was folding clothes on a table next to a barrel of soiled laundry in the laundry room. V5 stated, When I'm working with isolation laundry I wear a gown, mask, and eyewear. V5 was asked where the gowns were located. V5 stated, I'm not sure where the gowns are located if we have any in here. I wear a gown, so the laundry doesn't touch my arms or clothes. I don't wear a gown if the laundry isn't from an isolation room. On 4/5/23 at 1:44 p.m., V2 (DON) stated, Laundry staff don't have to wear gowns while handling soiled laundry unless it's COVID-19 positive laundry. If the staff are handling the laundry without a gown, then handling the clean laundry as well this could contribute to the spread of COVID-19. 3. On 4/4/23 at 1:00pm, V17, Contracted Laboratory Technician, applied gloves and performed a PCR (Polymerase chain reaction) lab test on R67. V17 removed his gloves, labeled the tube that he put R67's test into, then placed the tube in a plastic bin. V17 did not perform hand hygiene or use any hand sanitizer before applying gloves, then performing a PCR test on R26. V17 removed his gloves, placed the label on R26's tube, placed it in the bin. V17 did not perform hand hygiene, applied clean gloves and tested R64. V17 again removed the gloves and labeled the tube and placed it in the bin. All the testes were performed in the main dining area. V2, Director of Nursing, and V19, Cooperate Nurse, stopped V17, told him that testing could not be done in the main dining area. V17 stated that he did not have any specific training on long term care regulations and was not aware he could not do testing in the main dining room. V17 stated that he has not received instructions concerning infection control. V17 stated that he did not use or perform hand hygiene in the dining room, because he did not have hand sanitizer on the cart. On 4/6/23 at 12:30pm, V2, Director of Nursing, verified that PCR testing was not to be done in the main dining area. V2 stated that it is the facility policy to wear gowns, gloves, shields and N95 masks when COVID-19 testing. V2 stated that the contract with the laboratory will be rescinded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 10 of 10