Health inspection·August 12, 2022

F 0689 R57's Post Fall Analysis Worksheet dated 01/30/22 documents the following: Level of Harm - Minimal harm or potential for actual harm Circumstances at the time of the fall: Staff performing cares on resident. Resident rolled towards the wall and failed to stop rolling. Rolling (rolled) off the side of the bed and pushed the bed away from the wall. The same Post Fall Analysis Worksheet documents Interventions Implemented: Bed locked-staff assist of 2 (two) for bed mobility. Residents Affected - Few On 8/10/22 at 2:25 pm V6, Assistant Director of Nursing (ADON) stated V6, ADON completes all fall investigation in the facility. V6, ADON reviewed R57's fall investigation dated 1/30/22 and stated I (V6, ADON) remember (V9, Certified Nursing Assistant) was providing (R57's) care by herself (V9, CNA) when (R57) rolled out of bed. It shouldn't have happened. The bed was not locked properly, and (V9, CNA) should have had help positioning (R57) in bed during care. I (V6, ADON) educated staff and updated the care plan to reinforce these interventions. 2. R44's Physician Order Summary Report Sheet (POS) dated 08/10/22 documents the following diagnoses: Chronic Respiratory Failure with Hypoxia, Chronic Respiratory Failure with Hypercapnia, Anxiety Disorder, and Heart Failure Unspecified. The same POS documents the following: Oxygen at 4 (four) liters continuous (per nasal cannula) every day and night shift, related to Chronic Obstructive Pulmonary Disease. R44's Minimum Data Set (MDS) dated [DATE] documents the following: R44 has a Brief Interview of Mental status score of 15 out of a possible 15, indicating no cognitive impairment. The same MDS documents R44 ambulates with staff supervision and has had one fall with minor injury since the last quarterly MDS was completed. R44's (Formal) Fall Risk) assessment dated [DATE] documents R44 has a fall risk score of 60 (sixty). The same fall risk assessment documents a fall risk score of 45 or higher equals a resident is at high risk for falls. R44's Care Plan dated revised 07/14/22 documents the following: Ambulation/Restorative: Supervise for technique and safety, especially while handling his oxygen tank and assist him as needed. R44's same Care Plan documents: He (R44) needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. On 08/09/22 at 11:25 am, R44 was standing in R44's bedroom/bathroom entry hall. R44 was attaching a oxygen nasal cannula with six foot long oxygen tube to a portable, metal oxygen cylinder tank. The portable metal oxygen cylinder tank was cradled in a double tank wheeled oxygen caddy. In the same entry way to R44's had a second oxygen nasal cannula and tubing. The second nasal cannula had 20 (twenty) feet of oxygen tubing. The second nasal cannula hung on the resident bedroom doorknob with the oxygen tubing hanging down to the floor. The remainder of the 20-foot oxygen tubing was scattered haphazardly across the entry hall floor, and into the bathroom floor. The oxygen tubing was scattered in a cluster just inside the bathroom doorway. The end of the oxygen tubing was attached to an electric oxygen concentrator that sat against the wall in the bathroom. R44 stated I (R44) have never been given a bag to coil the extra oxygen tubing in, but that would be nice. It is a pain in the butt to navigate around this tube (oxygen) on the floor. On 8/10/22 at 9:55 am R44's was ambulating out of R44's bathroom and into R44's bedroom entry hall. R44 had R44's oxygen nasal cannula in R44's nares with the 20-foot oxygen tubing dangling to the floor. The remainder of the 20 feet of oxygen tubing laid on the floor haphazardly and directly in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 2 of 6 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 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 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 R44's path. The opposite end of the oxygen tubing was attached to the oxygen concentrator in R44's bathroom. R44 had a shuffling gait as R44 kicked the oxygen tubing repeatedly to get a clear path out of R44's bathroom and into the entry hallway of R44's room. V7, Registered Nurse (RN) was waiting outside R44's bathroom door as R44 came out of R44's bathroom. V7, RN acknowledged R44 had 20 feet of tubing scattered about the floor. V7, RN started coiling R44's excessive oxygen tubing around V7, RN's hand and stated This is definitely a trip hazard. I guess a infection control issue too. I will get him a bag to put this in. The facility Fall Policy dated 04/19/22 documents the following: Policy: Fall and Accident intervention and prevention. Purpose: The resident's environment will remain free from accidents and hazards as possible; and each resident will receive adequate supervision and assistance devices to prevent accidents. The guidelines for accident prevention are: 1. Identifying hazard(s) and risk(s). 2. Evaluation and analyzing hazard(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 3 of 6 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 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document appropriate rationale for extended use of as needed (PRN) psychotropic medication, failed to evaluate the need for continued use of PRN psychotropic medication, and failed to obtain and document consent for psychotropic medication. These failures affect four (R25, R51, R55, R57) of six residents residents reviewed for unnecessary medications on the sample list of 36. Findings include: 1. R55's Face Sheet (undated) documents the following diagnoses: Dementia without Behavioral Disturbance, Psychosis, and Anxiety Disorder. R55's Order Summary Report dated 8/10/22 documents the following anti-psychotic medication order: Seroquel, give 25mg (milligrams) one tablet by mouth as needed (PRN) for behaviors two times a day PRN. The start date for the medication is 5/14/22 and no end date is documented. There is no documentation in R55's electronic medical record of the physician's rationale for exceeding 14 days for the PRN Seroquel and no evaluation for continued PRN use. R55's Medication Administration Record (MAR) dated May 2022 documents R55 was administered two PRN doses of Seroquel after the initial 14 days. R55's June 2022 MAR documents R55 was administered 13 PRN doses of Seroquel and July 2022 MAR documents R55 was administered five PRN doses of Seroquel. On 8/10/22 at 3:25pm, V6 Assistant Director of Nursing (ADON) confirmed R55's Seroquel order has no end date or documentation for extended use over 14 days. The facility's Antipsychotic Medication Use Policy (2016) documents: The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. This Policy further documents PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication.2. R51's undated Face Sheet documents medical diagnoses of Dementia With Behavioral Disturbance, Palliative Care, Restlessness and Agitation, Major Depressive Disorder and Adjustment Disorder. R51's Physician Order Sheet (POS) dated August 1-31, 2022 documents a physician order starting 7/23/22 for Lorazepam 0.5 milligrams (mg) every three hours as needed for Restlessness and Agitation. R51's Medication Administration Record (MAR) dated August 1-31, 2022 documents R51 was administered Lorazepam 0.5 mg on 8/5/22 at 4:02 PM. R25's undated Face Sheet documents medical diagnoses of Dementia Without Behavioral Disturbances, Anxiety Disorder and Depression. R25's Physician Order Sheet (POS) dated August 1-31, 2022 documents a physician order starting 7/19/22 for Mirtazipine 7.5 mg daily for Depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 4 of 6 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 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R25's MAR dated August 1-31, 2022 documents R25 was administered Mirtazipine 7.5 mg daily on 8/1/22-8/9/22. On 08/10/22 at 01:40 PM V6 Assistant Director of Nursing (ADON) stated anytime a resident is prescribed a new Psychotropic medication or when the dosage of any Psychotropic medication is increased there should be a consent signed by the resident or resident representative. V6 ADON stated (R51) was prescribed Ativan and no consent has been obtained. (R51) has received this medication and (R51) is not alert and oriented. I am going to obtain a consent this afternoon with (R51) Power of Attorney (POA). V6 ADON stated R25 was prescribed Mirtazipine and also has no consent. V6 stated We (staff) have looked all over for the Psychotropic consents and are not able to find them. The consents should have been completed and were not. Surveyor: [NAME], [NAME] 3. R57's Physician Order Summary Report sheet (POS) dated 08/10/22 documents the following psychotropic medications: Duloxetine Hydrochloride capsule delayed release sprinkle 60 milligrams (mg), Give one capsule by mouth in the morning related to Major Depressive Disorder, Single Episode Unspecified, Start date 06/17/2021. The same POS documents: Alprazolam (Xanax) tablet 0.25 MG, give 1 tablet by mouth at bedtime related to Anxiety Disorder, Unspecified, start 07/20/2022. There is no documentation in R57's medical record of consent for R57's Duloxetine Hydrochloride and Alprazolam. On 8/11/22 at 2:30 pm V6, Assistant Director of Nursing stated We do not have consents for (R57's) psychotropics. The facility Policy for Psychoactive Medications undated documents the following: Informed Consent: Psychoactive medication shall not be prescribed or administered without the informed consent of the resident, the resident representative, the resident's guardian or other authorized representative. All psychoactive medications dose increases must have an informed consent. Additional informed consents are not required for a reduction in dosage leave or deletion of a specific medication. Side effects shall be described on the informed consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 5 of 6 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 145930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Pontiac Nursing Home 1225 South Ewing Drive Pontiac, IL 61764 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, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to dispose of expired refrigerated food, failed to date and label open refrigerated food, failing to maintain a can opener and mixer in a sanitary operable condition. These failures have the potential to affect all 65 residents residing in the facility. Findings include: 1. On 08/09/22 at 9:32 am, during the initial tour of the facility kitchen where residents meals are prepared, V4, Dietary Manager (DM), acknowledged the facility refrigerator had the following: A five pound, half full container of pasta salad with no open date; a five pound, half full container of cottage cheese with crusted edges at the top of the cottage cheese and no open date; a five pound, half full container of cucumbers and onions with no open date and a 24 ounce three-quarter full container of horseradish sauce that expired on 4/26/22. On 08 /09/22 at 9:40 am V4, Dietary Manager stated Those need thrown away. I (V4, DM) am not sure why they (food items above) weren't dated. I don't know why the horseradish wasn't thrown out when it expired. 2. On 8/9/229/22 at 9:50 am V4, DM acknowledged the facility tabletop can opener mount was corroded with black dried food- like particles. The same can opener had gears with built-up brown and black grease like substance and fragments of metal shavings. The same can opener had a silver veneer scraped off that exposed one half inch base metal rusted blade tip. V4, DM stated I did not realize the can opener was in this condition. It will be taken care of today. 3. On 8/11/22 at 10:00 AM full kitchen tour with V12, Assistant Dietary Manager acknowledged the facility had four 24 inches by 18-inch plastic cutting boards that were heavily stained and had food-like brown particles wedged into deep cracks throughout the cutting boards. V12, Assistant Dietary Manager / [NAME] stated Those cutting boards need to be replaced. I don't know how long they have been here, but they need to be replaced. They are in pretty bad shape. 4. On 8/11/22 at 11:18 am V4, DM acknowledged the facility had a large, two-foot-tall commercial sized table-top mixer. The table-top mixer underside attachment component had a build-up of rust and flaking silver paint veneer that exposed bare metal. The mixer underside attachment component also had brown and beige crusty food-like debris, just above the mixer bowl. V4, DM stated We probably shouldn't use this. I did not realize it (commercial sized mixer) had rust, and chipped paint. The Resident Census and Conditions of Residents report dated 08/09/22 documents 65 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145930 If continuation sheet Page 6 of 6