Inspection·May 24, 2023

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 implement its abuse policy of immediately investigating and reporting an allegation of physical abuses between two residents to the State Agency, for one of three residents (R1) reviewed for abuse, in the sample of 6. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (revised 10/24/22) directs staff, This facility affirms the right of our residents to be free form abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This will be done by: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment and making the necessary changes to prevent future occurrences and Filing accurate and timely investigative reports. R1's Nursing Progress Notes, dated 4/11/2023 at 8:23 P.M. document, (R1) got into a verbal argument with (R3) and (R3) became physically aggressive to (R1). This nurse intervened, separated the two and redirected (R1) to her room. Noted redness to (R1's) right arm, and verbalized pain. Applied cold compress to area. No bruises noted. (V2/Director of Nurses and V16/Former Administrator) informed and made aware. Will continue to monitor. On 5/15/23 at 1:10 P.M., V2/Director of Nurses stated she is unaware of a resident-to-resident altercation between (R1) and (R3) on 4/11/23. V2/Director of Nurses confirms she did not do an Investigation, nor was the State Agency notified, per facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 2 of 13 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 05/24/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported to the State Agency, for one of three residents (R1) reviewed for abuse, in the sample of 6. Residents Affected - Few FINDINGS INCLUDE: R1's Nursing Progress Notes, dated 4/11/2023 at 8:23 P.M. document, (R1) got into a verbal argument with (R3) and (R3) became physically aggressive to (R1). This nurse intervened, separated the two and redirected (R1) to her room. Noted redness to (R1's) right arm, and verbalized pain. Applied cold compress to area. No bruises noted. (V2/Director of Nurses and V16/Former Administrator) informed and made aware. Will continue to monitor. On 5/15/23 at 1:10 P.M., V2/Director of Nurses stated she is unaware of a resident-to-resident altercation between (R1) and (R3) on 4/11/23. V2/Director of Nurses confirms she did not do an Investigation, nor was the State Agency notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 3 of 13 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 05/24/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to investigate timely an allegation of physical abuse for one of three residents (R1) reviewed for abuse, in a sample of 6. Residents Affected - Few FINDINGS INCLUDE: R1's Nursing Progress Notes, dated 4/11/2023 at 8:23 P.M. document, (R1) got into a verbal argument with (R3) and (R3) became physically aggressive to (R1). This nurse intervened, separated the two and redirected (R1) to her room. Noted redness to (R1's) right arm, and verbalized pain. Applied cold compress to area. No bruises noted. (V2/Director of Nurses and V16/Former Administrator) informed and made aware. Will continue to monitor. On 5/15/23 at 1:10 P.M., V2/Director of Nurses stated she is unaware of a resident-to-resident altercation between (R1) and (R3) on 4/11/23. V2/Director of Nurses confirms she did not do an Investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 4 of 13 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 05/24/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to revise the plan of care for two of three residents (R1 and R2), reviewed for care plans, in a sample of 6. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Comprehensive Care Plans, dated 11/28/2012 directs staff, The facility will 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. The facility policy, Fall Prevention Program, dated 11/28/2012 directs staff, The Fall Prevention Program includes the following components: Care Plan incorporates identification of all risk/issue; Addresses each fall; Interventions are changed with each fall; Preventative measures. The facility policy, Skin Condition Assessment and Monitoring, dated (revised) 6/8/2018 directs staff, The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. 1. R1's (facility) Skin and Wound Evaluation form, dated 11/29/22 documents, Burn, Second Degree, Front of Left Thigh, In- House Acquired on 11/29/22, Measures 4.0 CM (Centimeters) X 1.4 CM X 0.1 CM with surrounding tissue: erythema: redness of the skin, Pain at dressing change. R1's Care Plan, dated 2/9/22 includes the following Focus area: (R1) has a potential for impairment to skin integrity related to poor safety awareness and history of falls. R1's care plan does not address the second degree burn that R1 sustained on 11/29/22. 2. R1's (facility) Fall-Initial Occurrence Report, dated 4/18/23 at 1:25 A.M. and signed by V12/Registered Nurse, documents, Unwitnessed fall at (R1's) bedside, (R1) observed laying on floor next to her bed, face down, in a pool of blood, moaning and groaning. Contributing Factors: Confused, forgets to use call light, Recent room change. Other factors: Was given IM Ativan at (10:53) P.M. for behaviors. Injuries: Left lower lip laceration. New interventions initiated immediately: Floor mat, Nonskid footwear, Safety checks every 15 minutes. Sent to ER (Emergency Room). R1's current Care Plan, dated 2/9/22 includes the following Focus Area, (R1) is at risk for falls related to weakness due to self-care deficit. R1's Care Plan documents that R1 had falls on: 2/20/22, 7/14/22, 7/18/22, 9/16/22, 9/24/22, 10/1/22, 10/28/22, 12/22/22 and 4/18/23. Interventions to reduce the risk of further falls for R1 do not include: Floor mat, Nonskid footwear, Safety checks every 15 minutes. 3. R2's Nursing Progress Notes, dated 4/17/23 at 7:09 A.M. document, (R2) spilled tea on abdomen causing a second-degree burn. Area cleansed with soap and water. Bacitracin applied to wound bed and covered with Border Foam dressing. R2's Care Plan, dated 9/28/22 includes the following Focus Area, (R2) has moisture associated skin damage to her buttocks related to incontinence and decreased mobility. R2's Care Plan does not address the second degree burn that R2 sustained on 4/17/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 5 of 13 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 05/24/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm On 5/15/23 at 3:15 P.M., V4/Care Plan Coordinator stated, I didn't update (R1 or R2's) Care Plan when (R1 and R2) sustained second degree burns from the hot food/beverages. At that time V4 verified she did not update R1' Care Plan with new interventions after she sustained a fall with injury on 4/18/23. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 6 of 13 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 05/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many 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** Facility Failures resulted in two deficient practice statements. A. Based on observation, interview and record review, the facility failed to serve hot cereal at a safe temperature to prevent a resident's second-degree burn (R1) and failed to notify the facility Administration so an investigation could be conducted, which resulted in another resident (R2) suffering a second-degree scalding burn after facility kitchen staff served a scalding hot beverage without performing the required safe temperature check prior to serving. R1 sustained a 4.0 CM (centimeter) X 1.4 CM X 0.1 CM second degree, blistered, painful wound to the left anterior thigh on 11/29/22 when she was served a bowl of hot cereal. After R1 had suffered a second-degree burn, facility staff did not document the accident in R1's Nurse's notes, did not notify facility administrative staff and therefore no subsequent evaluation of the situation or implementation of further safety interventions were developed. On 4/17/23, R2 was served a scalding hot cup of tea and sustained a 4.05 CM X 2.72 CM second degree, blistering burn to her abdomen after she spilled the beverage. Facility kitchen staff served the hot beverage from the hot beverage machine without checking the required temperature prior to serving. Nursing staff again did not notify facility Administrative Staff and no evaluation of the incident nor implementation of further safety interventions were developed prior to discovery on 5/16/23. These failures have the potential to affect 73 of the 74 residents currently residing the facility. These failures resulted in an Immediate Jeopardy. The immediacy was removed on 5/22/2023. FINDINGS INCLUDE: The (undated) facility policy, Precautions for Handling Hot Beverages directs staff, Staff will monitor, serve and hold hot beverages in a safe manner to prevent potential burns. The temperature for brewing and serving hot beverages will be based on the manufacture recommendations for the beverage equipment utilized in the (facility). Although the recommended settings for proper brewing may vary based on the equipment, it is recommended that the temperature of the equipment be set at the lowest possible temperature for adequate brewing; anticipated to be in the range of 160- 170 degrees Fahrenheit. The serving temperature should be approximately 10 -15 degrees less than the brewing temperature. It is suggested that brewing and serving temperatures of hot beverages are monitored on a monthly or quarterly basis to assure proper functioning of equipment. Additional precautions may be implemented: Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. Ensuring staff monitor the identified high- risk resident(S) during mealtimes and/or when hot beverages are served. Utilizing specialized spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning. The (undated) facility policy, Serving Temperatures for Hot and Cold Foods directs staff, Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum temperatures do not reflect the required temperatures needed for preparation, cooking or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 7 of 13 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 05/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many cooling of foods. Hot foods served at higher temperatures, based on resident preference, must be done cautiously because foods served too hot may potentially decrease food quality and possibly contribute to resident burns. Hot cereal: 135 degrees Fahrenheit to 170 degrees Fahrenheit. Hot beverages: Follow facility guidelines. The [NAME] will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. The manufacture guidelines for the facility hot beverage machine (NG C300 Black) documents, The liquid dispenser (NG C300) is a dispenser for the delivery of coffee, tea and only hot water in commercial sectors. Warning: The liquids delivered by the dispenser are hot. Avoid scalding. The hot beverage machine Work Order dated 5/16/23 documents, (Facility) wants to know the temperature setting on their machine and would like the machine checked. Last check on 5/13/21. Solution: Replaced filter. Replaced temperature probe. Adjusted temperature from 194 degrees to 185 degrees, per customer (request). The (facility) Food Temperature Log Sheet, provided by V9/Cook directs staff to check food temperatures for Breakfast for eggs, scrambled eggs, oats, super cereal, and pureed eggs. No direction for checking temperatures of hot beverages is given. The facility Food Temperature Chart dated 4/30/23 through 5/15/23 documents the food temperature of the hot cereal served to facility residents during that time period ranging from 200 degrees Fahrenheit on 5/7/23 to 178 degrees on 5/8/23. No recorded temperatures of hot beverages are documented during this time frame. The current State Operations Manual, documents the following concerning burns: Table 1. Time and Temperature Relationship to Serious Burns Water Temperature Time Required for a 3rd Degree Burn to Occur 155°F 68°C 1 sec 148°F 64°C 2 sec 140°F 60°C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 8 of 13 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 05/24/2023 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 0689 5 sec Level of Harm - Immediate jeopardy to resident health or safety 133°F Residents Affected - Many 15 sec 56°C 127°F 52°C 1 min 124°F 51°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing (see Note) NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. A. 1. R1's (facility) admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Dementia with Behavioral Disturbance, Conversion Disorder with Seizures, Anxiety Disorder and Age- Related Cognitive Decline. R1's May 2023 Physician Order Sheet includes the following physician orders: General diet, add Super Cereal (hot cereal) at breakfast. R1's (facility) Skin and Wound Evaluation form, dated 11/29/22 documents, Burn, Second Degree, Front of Left Thigh, In- House Acquired on 11/29/22, Measures 4.0 CM (Centimeters) X 1.4 CM X 0.1 CM with surrounding tissue: erythema: redness of the skin, Pain at dressing change. R1's (facility) Wound Evaluation with photographs, dated 11/29/22 documents a reddened wound with currently blisters present, measured as 4.01 CM X 1.37 CM X 0.1 CM. The wound is described as painful at dressing change with a daily treatment in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 9 of 13 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 05/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many R1's Initial Wound Evaluation and Management Summary, dated 12/7/22 by V15/Wound Doctor documents, (R1) presents with a wound on her left thigh. (R1) has a burn wound of the left thigh for least 1 day's duration. There is moderate serous exudate. Burn wound measures 4.5 CM X 1 CM X 0.1 CM with moderate, serous exudate. 15% slough and 35% granulation tissue. Procedure Note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.1 CM and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 15 percent to 5 percent. Hemostasis was achieved and a clean dressing was applied. Dressing Treatment Plan: Silver sulfadiazine apply three times per week for 30 days. Alginate calcium apply three times per week for 30 days. Foam silicone border dressing. Skin prep to the peri wound. R1's Wound Evaluation and Management Summary, dated 12/14/22 documents, (R1) presents with a wound to her left thigh. (R1) spilled hot oatmeal on her leg, causing a burn wound. Current wound size: 3 CM X 1 CM X 0.1 CM. Procedure Note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.1 CM and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 15 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied. R1's (facility) Wound Evaluation, dated 12/28/22 documents, Burn wound to left thigh measures 1.1 CM X 0.71 CM X 0.1 CM. Wound bed is 100% epithelial tissue. Progress: Healed. On 5/15/2023 at 1:45 P.M., V5/Registered Nurse verified she did fill out the wound information sheet for R1's leg wound. V5 also verified that R1 feeds herself after staff prepared her food and R1 dropped a bowl of hot cereal on her leg, causing injury. V5/RN verified she did not tell V1/Administrator or V2/DON about (R1's) injury but did obtain a wound treatment for the injury. V5 stated that R1 complained of much pain when wound treatment was being done and stated R1 saw the facility Wound Doctor about a week after the injury happened. On 5/16/23 at 9:39 A.M., V9/Cook stated, We don't currently have a Dietary Manager. We haven't had one for about a month. Dietary Managers from other facilities take turns coming here and looking things over. The [NAME] is responsible for temping each food offered prior to the start of the meal. At that time, V9 was only able to produce the facility Food Temperature Logs from 4/30/23 through 5/15/23. V9/Cook verified temperature checks of the cooked cereal were between 178 degrees and 200 degrees. At 9:57 A.M., V9/Cook stated, We don't check the temperature of hot beverages (prior to serving). I suppose we could start doing that. At that time, V9/Cook verified the temperature of a cup of hot water/coffee from the facility hot beverage machine was 190 degrees. V9/Cook also verified all 73 facility residents receive meals and beverages form the facility kitchen, except one resident who receives gastrostomy tube feedings. On 5/16/23 at 10:00 A.M., V10/Dietary Manager of sister facility who was over-seeing the facility kitchen stated, Kitchen staff should always check the temperature of hot beverages prior to serving. We always check hot beverage temperatures at the facility I have worked at for the past 16 years. Hot food/hot beverages can cause severe burns in elderly residents. 190 degrees is too hot. 2. R2's (facility) admission Record documents that R2 was admitted to the facility on [DATE] with the following diagnoses: Lack of Coordination, Abnormal Posture, Weakness and Anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 10 of 13 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 05/24/2023 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 0689 R2's May 2023 Physician Order Sheet includes the following physician orders: General, Regular Diet. Level of Harm - Immediate jeopardy to resident health or safety R2's Nursing Progress Notes, dated 4/17/23 at 7:09 A.M. document, (R2) spilled tea on abdomen causing a second-degree burn. Area cleansed with soap and water. Bacitracin applied to wound bed and covered with Border Foam dressing. Residents Affected - Many R2's Wound Evaluation, dated 4/18/23 documents, Second degree burn to lower left abdomen, measures 4.05 CM X 2.72 CM, acquired in- house on 4/17/23. 90% granulation tissue present with light serous drainage. Treatment in place. R2's Wound Evaluation, dated 5/9/23 documents, Second degree burn to lower abdomen, measures 3.79 CM X 2.76 CM X 0.1 CM. 100% granulation tissue present with light serous drainage. Progress: Healing. On 5/16/23 at 1:17 P.M., R2 stated she likes hot tea at each meal and usually the temperature is warm when she receives it. However, on that day (4/17/23), her tea was extremely hot and when she spilled it, it caused a painful burn. R2 stated the area was painful, especially when dressing was changed. Observation of area at that time shows an 8 CM X 4 CM healing burn to (R2's) lower left abdomen. The facility Room Roster dated 5/15/23 documents 74 residents currently reside in the facility. The Immediate Jeopardy began on 11/29/22 at 1:29 P.M. when R1 was served a bowl of hot cereal. After R1 had suffered a second-degree burn, facility staff did not document the accident in R1's Nurse's Notes, did not notify facility Administrative Staff and therefore no subsequent evaluation of the situation or implementation of further safety interventions were developed. V1/Administrator was notified of the Immediate Jeopardy on 5/22/23 at 1:35 P.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 and R2 incidents were both reported to IDPH (State Agency) on 5/16/2023. 2. The dietary assistant manager has been in-service on the safe temperature range for serving hot food and beverages. Training completed on 5/22/23 by Administrator. 3. All dietary staff have been in-serviced on performing hot beverage and food temps prior to each meal. They have also been in-serviced on interventions/measures required if hot food and beverages are not within an acceptable range. Staff's knowledge was evaluated based on a quiz. Any staff that do not have sufficient knowledge base will be re-trained and retested. Training initiated on 5/22/23 by Administrator and anyone on FMLA (Family Medical Leave Act) or vacation will be educated via phone and again before next scheduled shift. 4. The Director of Nursing has been educated on what constitutes an Incidents/Accidents and the timely reporting criteria for all unexplained bruises and abrasions, incidents and accidents with injury or the potential to result in injury. Training was completed on 5/22/23 by RNC (Regional Nurse Consultant). 5. The facility will check temperatures of hot foods and beverages at every meal to ensure hot food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 11 of 13 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 05/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many and beverages are at appropriate serving temperature. A QA (Quality Assurance) tool was completed to verify this practice has occurred. The QA tool will be completed by the dietary assistant manager or designee, for 6 weeks. There will be oversight of the QA tool by Administrator. 6. All nursing staff have been educated on what constitutes an incident/accident and the timely reporting on incidents/accidents for all unexplained bruises or abrasions, and all accidents or incidents where there is an injury. Staff's knowledge competencies will be based on a written quiz. Any staff that do not have sufficient knowledge base will be re-trained and retested. Training initiated on 5/22/23 by RNC or DON (Director of Nurses) anyone on PRN (as needed) status, FMLA or vacation will be educated via phone and again before next scheduled shift. 7. An impromptu QAPI (Quality Assurance and Performance Improvement) meeting was held with the (facility) Medical Director and staff IDT (Intra Disciplinary Team) team to discuss deficiency and facility action plan on 5/22/23. 8. The facility will read the progress notes daily to ensure a potential incidents/accidents have been captured as such and have appropriate follow up. A QA tool will be completed to verify this practice has occurred. The QA tool will be completed by DON or designee, daily for 6 weeks. There will be oversight of the QA tool by RNC or DON on 5/22/23 and on-going. 9. The coffee machine has been serviced by technician on 5/16/2023 resulting in adjusted dispensing temperature of 150-170 degrees as per policy. Completion Date: This plan was completed on May 22, 2023. B. Based on interview and record review, the facility failed to provide increased supervision after administration of two (as needed) psychotropic medications within a two-hour time span, resulting in a resident falling from a bed, sustaining a laceration and a head injury for one resident (R1) of three residents reviewed, in a sample of 6. The facility policy, Fall Prevention Program, dated 11/28/2012 directs staff, To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Use and implementation of professional standards of practice. In addition to the use of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk: The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care. R1's (facility) admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Dementia with Behavioral Disturbance, Conversion Disorder with Seizures, Anxiety Disorder, Age- Related Cognitive Decline, Insomnia, Lack of Coordination, Abnormal Posture and Weakness. R1's current Physician Order Sheet, dated May 2023 includes the following medications: Risperidone (antipsychotic) 1 MG (Milligram) by mouth in the morning and 0.5 MG by mouth at bedtime; Mirtazapine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 12 of 13 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 05/24/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety (antidepressant) 30 MG by mouth at bedtime; Ativan (antianxiety) 0.5 MG by mouth every 6 hours as needed; and Ativan Injection 2 MG/ML (Milliliters) Inject 1 ML intramuscularly every 12 hours as needed for agitation and anxiety. R1's Fall Risk Assessment, dated 01/31/2023 documents R1 is at high risk for falls (Score 21) (High Risk is 10 or greater). Residents Affected - Many R1's current Care Plan, dated 2/9/22 includes the following Focus Area: (R1) is at risk for falls related to weakness due to self-care deficit. R1's Care Plan documents R1 had falls on: 2/20/22, 7/14/22, 7/18/22, 9/16/22, 9/24/22, 10/1/22, 10/28/22, 12/22/22 and 4/18/22. This same Care Plan includes another Focus Area, (R1) uses an anti-anxiety medication related to anxiety disorder. Interventions include, Administer anti-anxiety medication as ordered by physician. Monitor for side effects and effectiveness. Monitor/document/report any adverse reactions: Drowsiness, lack of energy, clumsiness, slow reflexes, confusion and disorientation, dizziness, impaired thinking and judgement, blurred or double vision. R1's April 2023 Medication Administration Record documents that R1 received the following medications on 4/17/2023: Ativan 2 MG/ML (1 MG) intramuscularly at 2:11 P.M. due to behaviors; Ativan 0.5 MG PO at 8:14 P.M. for agitation and anxiety; and Ativan 2 MG/ML (1 MG) intramuscularly at 10:53 P.M. for agitation. R1's (facility) Fall-Initial Occurrence Report, dated 4/18/23 at 1:25 A.M. and signed by V12/Registered Nurse, documents, Unwitnessed fall at (R1's) bedside, (R1) observed laying on floor next to her bed, face down, in a pool of blood, moaning and groaning. Contributing Factors: Confused, forgets to use call light, Recent room change. Other factors: Was given IM Ativan at (10:53) P.M. for behaviors. Injuries: Left lower lip laceration. New interventions initiated immediately: Floor mat, Nonskid footwear, Safety checks every 15 minutes. Sent to ER (Emergency Room). R1's emergency room Report, dated 4/18/23 documents, (R1) resides at (facility) and presents to ER for evaluation of head injury and lip laceration after a fall out of bed. The (facility) gave (R1) some Ativan because of agitation at bedtime. (R1) then rolled out of bed and struck her head. Exam: Evidence of contusion to the face with lip laceration. Diagnosis: Head Injury, Head Contusion, Lip Laceration. On 5/16/23 at 11:13 A.M., V12/Registered Nurse denied providing increased supervision for R1 after facility staff had administered three additional doses of Ativan to R1, within a 10-hour period. V12/Registered Nurse stated, I was the nurse the night that (R1) fell from bed. I work 6 P.M. to 6 A.M. and R1 was having behaviors all night. (R1) wouldn't take her medications; (R1) was very anxious and combative. I gave her an extra dose of (oral) Ativan at 8:14 (P.M.) and (R1) was still having behaviors, so I called (R1's) doctor and got an order for I.M. (Intramuscularly) Ativan. It took three additional staff members help for me to give (R1) the shot. I gave it around 10:53 P.M. Around 11 (o'clock P.M.) I noticed (R1) was falling asleep in her wheelchair. A couple of hours later I heard a movement and a sound like something fell. I found (R1) lying face down in a pool of blood. I sent (R1) to the ER. We didn't do anything special for (R1) after I gave (R1) the shot. We just put (R1) to bed, like normal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 13 of 13