Health inspection·March 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide timely call light response for four (R17, R38, R45, R206) of nine residents reviewed for call light response times in the sample list of 27. Findings include: On 3/25/25 at 9:00 am, R206 stated that R206 needed assistance from staff, and R206 was unsure why they took so long to come to R206's room. R206 stated sometimes R45 (R206's roommate) has to wait 45 minutes or more for staff to come and put R45 into bed. R206 stated that sometimes R206 will wheel down the hall to get staff to come and help R45. Facility Census documents R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture, and Muscle Wasting and Atrophy. R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score of 8, moderate cognitive impairment, and needs moderate assistance with showers/bathing. On 3/25/25 at 9:15 am, R45 stated that sometimes R45 has to wait 45 minutes or more for staff to come and help R45 into bed. R45 stated that R206, R45's roommate, will get staff to help R45. R45's Minimum Data Set (MDS) dated [DATE] documents R45's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and needs substantial/maximum assistance with showers/bathing. On 3/25/25 at 11:24am R38 stated that it takes staff to long to answer call lights sometimes. R38 stated that R38 needed assistance from staff to get transferred to the toilet. R38 stated that in more than one instance R38 has had an incontinent episode, due to waiting on staff to come toilet R38. R38 stated, R38 sometimes has to wait 30-40 minutes for staffs' assistance. Facility Census documents R38 was admitted to the facility on [DATE] and has the following medical diagnoses: Parkinson's Disease, Major Depressive Disorder, and Post-Traumatic Stress Disorder. R38's Minimum Data Set (MDS) dated [DATE] documents R38's Brief Interview for Mental Status (BIMS) score 15, cognitively intact and needs substantial/maximum assistance with showers/bathe. On 3/26/25 at 9:00am, a resident council meeting was held. During the meeting R206 stated it takes a long time for call lights to be answered, R206's roommate (R45) calls out, so R206 turns the call Page 1 of 4 145911 145911 03/28/2025 Goldwater Care Gibson City 620 East First Street Gibson City, IL 60936

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some light on for R45. R206 stated R206 has had to go looking for staff because no one responds to the call light. R206 stated R206's/R45's room gets overlooked because it is at the end of the hallway. R17 stated R17 has waited for over an hour for R17's call light to be answered, especially during the afternoon and midnight shifts. R17 stated R17 waits a long time for the call light to be answered and often ends up getting out of bed by herself, but R17 is supposed to have assistance from staff. These residents stated that call light wait times have been an ongoing issue brought up in the resident council meetings that haven't been resolved. On 3/26/25 at 9:15am R17 stated that staff take a long time to answer call lights and R17 needs help to get to the toilet. R17 stated we have been bringing it up at the monthly resident council meeting and nothing seems to get done, it's not getting any better. Facility Census documents R17 was admitted to the facility on [DATE] and has the following medical diagnoses: Parkinson's Disease, Major Depressive Disorder, and Post-Traumatic Stress Disorder. R17's Minimum Data Set (MDS) dated [DATE] documents R17's Brief Interview for Mental Status (BIMS) score 15, cognitively intact and needs Partial/moderate assistance with showers/bathe. On 3/26/25 at 9:20am V5 Activity Director confirmed call lights have been an ongoing concern brought up in the resident council meetings. V5 stated that for the past two monthly Resident Council meetings residents have been complaining on waiting a long time for call lights to be answered. On 3/26/25 at 10:30 a.m., the V1 Administrator stated that V1 is aware of the delay in answering residents' call lights. V1 stated that the facility has been educating staff on answering call lights in a timely manner, but residents are still complaining that the staff is taking too long to answer them. V1 stated that some residents are taking themselves to the toilet due to staff not responding in a timely manner. The Resident Council Minutes dated 1/27/25 and 2/24/25 document concerns with call light response times taking too long. Facility Call Light Policy dated 2/2/18 documents Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Residents' call lights will be answered in a timely manner. 1. All residents who can use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to a room to respond to call system and promptly cancel the call light when the room is entered. 5. Hand bells will be provided for alert dependent resident's when positioned out of reach of permanent call light when needed. 6. Call bell system defects will be reported promptly to Maintenance Department for servicing. Check room frequently until system is repaired. 145911 Page 2 of 4 145911 03/28/2025 Goldwater Care Gibson City 620 East First Street Gibson City, IL 60936

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide numerous showers as scheduled for two (R45, R206) of three residents who were reviewed for showers in the sample list of 27. Residents Affected - Some Findings include: 1. On 3/25/25 at 9:00am R206 was sitting in the wheelchair in R206's room, nails not trimmed and face not shaven. On 3/25/25 at 9:00 am R206 stated that R206 was admitted a couple of weeks ago and has only gotten one shower last week. R206 stated that staff do not cut R206's nails on that day or any other day; they are very long and need trimming. The Facility Census documents that R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture and Muscle Wasting and Atrophy. R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment and needs moderate assistance with showers/bathe. The Facility's East Evening Showers schedule documents R206 is scheduled to receive showers on Tuesdays and Fridays. R206's Shower Day Skin Inspection report documents R206 received showers on 3/21/25 and has no documented refusals or bed baths. The same report documents R206's nails were never cut or trimmed. 2. On 2/25/25 at 9:15am R45 was sitting in the wheelchair in R45's room, nails not trimmed. On 2/25/25 at 9:15am R45 stated that R45 never gets two showers a week. R45 stated that staff never cut or trim R45's nails, and they are long and need trimming. R45's Minimum Data Set (MDS) dated [DATE] documents R45's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and needs substantial/maximum assistance with showers/bathing. The Facility's East Evening Showers schedule documents R45 is scheduled to receive showers on Tuesdays and Fridays. R45's Shower Day Skin Inspection report documents R45 received showers on 2/11/25, 2/18/25, 2/28/25 and 3/21/25, refused showers on 2/25/25, 3/11/25 and 3/14/25 and was not offered a bed bath. The same report documents that R45's nails were never cut or trimmed. On 2/26/25 at 1:30 p.m., V2, the Director of Nursing, stated that all residents are scheduled two showers a week and should be getting them. V2 stated that after a resident receives a shower, bed bath, or refuses a shower, the Certified Nursing Assistant is required to complete a Shower Day Skin Inspection Form. V2 confirmed that R45 and R206 are not receiving two showers a week and will have staff cut their nails today. 145911 Page 3 of 4 145911 03/28/2025 Goldwater Care Gibson City 620 East First Street Gibson City, IL 60936

F 0677 Level of Harm - Minimal harm or potential for actual harm The Facility's Shower Documentation documents showers should always include washing hair, oral care, fingernails, toenails (except diabetic residents), shaving, stripping and remaking the bed, cleaning the shower room. Please make sure you're performing each of these when giving a shower. Shower reminders: refusals or N/A's require a shower sheet be completed with reason (showered on AM shift, showered yesterday by hospice, res states does not feel like it). Residents Affected - Some 145911 Page 4 of 4