Health inspection·February 5, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or any restorative aides. I guess the CNAs (Certified Nursing Assistants) do restorative stuff and document it. On 02/04/25 at 9:07 A.M., V7/Care Plan Coordinator stated, We don't have a restorative nurse or restorative aides. I don't think we have any restorative programs (including Range of Motion). I don't add any programs to the care plan. On 02/04/25 at 9:11 A.M., V10/Director of Rehab (Rehabilitation) stated, We don't have a restorative nurse or restorative aides. When a resident comes off of skilled therapy we fill out a Therapy to Nursing Recommendations form and give it to the nursing staff. It isn't a formal program, it's a restorative recommendation, meaning we recommend that a restorative program be implemented and performed by staff. I do a quarterly screens, but it's not a contracture screen. On 02/04/25 at 9:21 A.M., V2/Director Of Nurses verified that R2 did not have a restorative Passive Range of Motion program to address R2's multiple contractures. On 02/04/25 at 9:25 A.M., R2 stated, No one does range of motion (exercises) with me. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 2 of 9 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 02/05/2025 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 - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to implement fall precautions for one of five residents (R43), reviewed for falls in a sample of 36. Residents Affected - Few The facility policy, Fall Prevention Program, dated (revised) 11/21/17 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. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The fall prevention program includes the following components: Methods to identify residents at risk, communication with direct staff members. Safety interventions will be implemented for each resident identified at risk. Fall/safety interventions may include, but are not limited to: Nursing personnel will be informed of residents who are at risk for falling. R43's current Physician Order Sheet, dated February 2025 includes the following diagnoses: Dementia, Depression, Anxiety and Chronic Pain. R43's Nursing Progress Note dated 9/6/2024 documents, Summary of the fall: (R43) with gait imbalance due to dementia with behavioral disturbance, MDD (Major Depressive Disorder), Anxiety, HTN, and protein calorie malnutrition had an unwitnessed fall in (the) dining room. (R43) was ambulating with cane for assist, to her normal dining room chair. Activities employee was present but turned to help another resident. (R43's) mobility status was able to walk with cane unassisted. (R43) fell backwards hitting her head on the floor. Back of head assessed per nurse, no bleeding noted but closed injury occurred as hematoma was palpable. EMS (Emergency Medical Services) contacted and transported resident to hospital. Visual signs placed in room to call for help and (R43) described as increased fall risk. R43's Nursing Progress Notes, dated 9/11/2024 at 09:20 A.M .document, Summary of the fall: On rounds, (R43) observed lying on her left side on the floor next to her bed alert and talking. Resident had placed a pillow under her head. Call light was on bed within reach and proper footwear on. (R43) stated I don't know what happened just call the ambulance and call my son. Do not touch me, don't move me just call the ambulance. The nurse was able to obtain her vitals which were stable. No bruising or injury noted. Resident had a previous fall on 9/5/24 in which she did hit her head. (R43) was made comfortable on floor with blankets and pillows and EMS notified. (R43) remained alert and talking. (R43) had ER (Emergency Room) visit only. Repeat CT (Computerized Tomography) of head negative. No new orders. R43s Nursing Progress Notes, dated 1/22/2025 document, Summary of the fall: (R43) was heard by the nurse from the hallway asking for some help. When the nurse entered the room, (R43) was observed sitting on her buttocks on the floor next to her bed. Bed was in the lowest position, call light in reach but not activated, and regular socks on. Her pants were down around her thighs. Resident states she was trying to get out of the bed. (R43) assessed, no injuries present, ROM (Range of Motion) and neuro's (neurological) at baseline. On 2/2/2025 at 9:13 A.M., (R43) was asleep in bed. No Falling Leaf to designate resident as at risk for falls, was present on (R43's) door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 3 of 9 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 02/05/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/2/2025 at 11:03 A.M., V11/Licensed Practical Nurse stated, When a resident is at risk for falls, we place a leaf on the resident's door so staff will know the resident is at risk and to check on them more often. At that time, V11/Licensed Practical Nurse verified that R43 was at risk for falls and a leaf was not present on R43's door. On 2/3/2025 at 2:27 P.M., V2/Director Of Nurses stated she was responsible for the facility Fall Program. V2/DON verified that when a resident is at risk for falls or has a history of falls, a leaf symbol is placed on the resident's room door, next to their name, to designate that resident as high risk for falls and to alert staff to provide increased observations. At that time, V2/DON also verified that R43 did not have a leaf symbol outside her room door, despite the fact that she had a recent fall and has a history of falls. Event ID: Facility ID: 145486 If continuation sheet Page 4 of 9 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 02/05/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to perform urinary catheter care to reduce the risk of infection for one of two residents (R221) reviewed for urinary catheters, in a sample of 36. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Urinary Catheter Care, dated (revised) 2-14-19 directs staff, To establish guidelines to reduce the risk of or prevent infections with an indwelling catheter. The following should be discouraged: Use of antiseptic/antimicrobial solutions for cleansing during catheter care. Routine hygiene (cleansing of the meatal surface during daily bathing or showering) is appropriate. Encrustations on the foley catheter should be removed from the meatus outward with a clean wash cloth, rinsed with clean water on an as needed basis. R221's current Physician Order Sheet, dated February 2025 includes the following diagnoses: Traumatic Amputation Below the Left Knee, Stage 3 Pressure Ulcer Right Buttock, Stage 4 Pressure Ulcer Left Buttock, History of Urinary Tract Infection. This same form includes the following physician orders: (Indwelling Urinary) Catheter 18 FR (French) 30 CC (Cubic Centimeters) Change monthly and as needed. (Urinary Catheter) Cares every shift. On 02/02/25 at 10:36 A.M., V3/Infection Preventionist Nurse and V11/Licensed Practical Nurse (LPN) prepared to perform urinary catheter care for R221. V11/Licensed Practical Nurse squirted a 3 CC vial of normal saline onto a 4 X 4 gauze pad and wiped down the middle of R221's peri area. At that time, V3/Infection Preventionist handed V11/Licensed Practical Nurse a package of moisturizing peri wipes. V11/Licensed Practical Nurse took a handful of wipes and wiped the left side of R221's peri area, grabbed another handful of wipes and wiped the right side of R221's peri area. V11/LPN removed her gloves and assisted in repositioning R221 and left the room. On 02/04/25 at 11:08 A.M., V2/Director Of Nurses stated, Our policy for catheter care is to cleanse (the peri area and meatal surface) with soap and water. We don't use peri wipes as a cleanser. They can be very irritating and irritated skin can lead to urinary tract infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 5 of 9 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 02/05/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to document a rationale for the continued use of an antibiotic for one of two residents (R2), reviewed for unnecessary medications in a sample of 36. Residents Affected - Few Findings Include: The facility policy, Antibiotic/Antimicrobial Stewardship Program, dated 11/28/2017 directs staff, This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program will help ensure that our residents get the right antibiotics at the right time for the right duration, and can help improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections and reduce healthcare costs. This facility utilizes the McGeer's Criteria for determining if an infection meets criteria for treatment with an antibiotic. R2's current Physician Order Sheet, dated February 2025 documents, 11/11/2024 Nitrofurantoin 100 MG (Milligrams) one capsule by mouth one time a day related to Personal History of Urinary Tract Infections. No stop date is included for the antibiotic usage. On 2/4/23 at 9:09 A.M., V2/Infection Preventionist stated, (R2) is on continuous antibiotics due to a history of urinary tract infections. I didn't realize the antibiotic was started that long ago. There is no stop date for the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 6 of 9 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 02/05/2025 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 perform hand hygiene during medication administration for one of two residents (R48) reviewed for medication administration, in a sample of 36. Residents Affected - Few FINDINGS INCLUDE: The (undated) facility policy, Medication Administration General Guidelines, directs staff, Medications are administered as prescribed in accordance with good nursing principals and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Examination gloves are worn when necessary. R48's current Physician Order Sheet, dated February 2025 includes the following medications: Aspirin 81 MG (Milligrams) one tablet by mouth in the morning; Calcium 600 MG with Vitamin D3 10 MG one tablet by mouth one time a day; Cetirizine 10 MG one tablet by mouth one time a day; Docusate Sodium 100 MG one capsule by mouth one time a day; Multivitamin one tablet by mouth one time a day; Omeprazole 20 MG one capsule by mouth one time a day; Simethicone 80 MG one tablet by mouth two times a day. On 02/03/2025 at 7:49 A.M., V14/Registered Nurse prepared to administer medications for R48. V14/Registered Nurse opened the top drawer of the mobile medication cart and withdrew community, stock medications bottles, opened each bottle and poured one tablet each of Aspirin, Calcium/Vitamin D, Docusate Sodium, Multivitamin, Simethicone and one capsule of Omeprazole into her ungloved hand and placed each pill in a small, plastic medication cup. V14/Registered Nurse placed the medication cup in front of R48 with a glass of water and R48 took each pill. Upon return to the medication cart, V14/Registered Nurse confirmed she she touched each of R48's pills with ungloved hands. On 02/04/2025 at 2:53 P.M., V2/Director of Nurses stated, Nurses should not touch medications, they are preparing for administration, with their ungloved hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 7 of 9 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 02/05/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to identify, monitor, and review prophylactic antibiotic use for five (R1, R2, R33, R54, and R67) of five residents reviewed for antibiotic stewardship in the sample of 36. Residents Affected - Some Findings include: The facility's Infection Surveillance, Tracking and QA (Quality Assurance) Reporting policy and procedure, dated 2/14/18 documents infection tracking includes: Completing Infection Tracking Log for all residents with an infection and/or treated with antibiotics. Review documentation of clinical signs and symptoms to determine if McGeer's criteria for infection were met and antibiotic use is appropriate. The facility's Antibiotic/Antimicrobial Stewardship Program policy, dated 11/28/17, documents This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections, and reduce healthcare costs. The Medical Director will set standards for antibiotic prescribing practices for all physicians providing care in the facility, review antibiotic use data gathered by tracking and monitoring, and provide feedback and recommendation to ensure that best practices are followed in the medical care of residents in the facility. The Director of Nursing and/or in conjunction with the Infection Control Officer will be responsible for setting the standards for assessing, monitoring and communicating changes in a resident's condition by the nursing staff providing direct care. Data gathered each month related to antibiotic use and treatment of infections will be submitted and reviewed by the QA Committee, and action plans developed as identified and recommended. Data will be compared month to month to identify trends and improvements made to work toward a long-term goal. On 2/4/25 at 12:00 pm, V3 ADON (Assistant Director of Nursing) stated she is the ICP (Infection Control Preventionist) for the facility and tracks all the residents antibiotic use, date started, the organism and stop dates. V3 stated she does not keep track or review the residents who are currently on prophylactic antibiotics and is unsure who is currently receiving prophylactic antibiotics, does not get a list of those antibiotics from the pharmacy and they are not discussed in the facility's monthly QA (Quality Assurance) Meetings. On 2/4/25 at 2:10 pm, V3 ADON/ICP stated she found that (R2), (R67), and (R1) are currently on prophylactic antibiotics. V3 stated she called the facility pharmacy and is waiting to hear back to find out how to find out if there are currently any other residents on prophylactic antibiotics. V3 stated she only reviews and monitors residents on prophylactic antibiotics when they are first initiated and then does not do anything else with them. On 2/4/25 at 2:30 pm, V3 ADON/ICP provided an Order Listing Report, dated 2/4/25, for Residents currently on antibiotics. This report documents R1, R2, R33, R54, and R67 are currently receiving prophylactic antibiotics. The January 2025 Monthly Infection Log Report does not include R1, R2, R33, R54, and R67 as receiving any antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 8 of 9 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 02/05/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. The Order Summary Report for R1, dated 2/4/25 documents a 2/24/22 physician order for the antibiotic Nitrofurantoin 50 mg (milligrams), one capsule by mouth daily related to Long Term (current) use of antibiotics. There is no documented stop date or diagnosis for this antibiotic. 2. On 2/3/25 at 9:00 am, R2's bedroom door held a Contact Precautions sign giving instructions to staff and visitors prior to entering R2's bedroom. The Order Summary Report for R2, dated 2/4/25 documents a 11/11/24 physician order for the antibiotic Nitrofurantoin 100 mg, one capsule daily related to Personal History of Urinary Tract Infections. There is no documented stop date. 3. The Order Summary Report for R33, dated 2/4/25 documents the following dated antibiotic orders for DMAC (Disseminated Mycobacterium Avium-Intracellular Complex) as: 7/20/21 physician order for the antibiotic Azithromycin 500 mg one tablet daily; 10/01/21 physician order for the antibiotic Ethambutol 100 mg three tablets in the morning; 10/02/21 physician order for the antibiotic Ethambutol 400 mg two tablets in the morning; and 10/01/21 physician order for the antibiotic Rifampin 300 mg two capsules in the morning. There are no documented stop dates. 4. The Order Summary Report for R54, dated 2/4/25 documents a physician order for the antibiotic Macrodantin 50 mg one capsule at bedtime for UTI (urinary tract infection) Suppression. There is no documented stop date. 5. The Order Summary Report for R67, dated 2/4/25 documents the following dated antibiotic orders as: 11/15/24 Ciprofloxacin 500 mg one tablet daily for Spontaneous Bacterial Peritonitis prophylaxis and 11/15/24 Rifaximin 550 mg one tablet two times daily for Liver Disease. There are no documented stop dates. On 2/4/25 at 2:31pm V3 ADON/ICP stated (R33) has been here for a long time and I had no clue R33 was on all the antibiotics. V3 also confirmed she was unaware that R54 and R1 were also on prophylactic antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145486 If continuation sheet Page 9 of 9