Health inspection·April 18, 2024

F 0568 Level of Harm - Potential for minimal harm Residents Affected - Many Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on interview and record review, the facility failed to ensure a quarterly statement of the resident's financial record was provided. This failure has the potential to affect all 43 residents currently residing in the facility. Findings Include: The facility's Resident Right Manual, provided to all residents at time of admission, documents the following: Your rights regarding your money. You have the right to manage your own money. The facility must not require you to let them manage your money or be your Social Security representative payee. If you ask the facility to manage your money, it may only spend your money with your permission. It must give you a current, itemized written statement at least once every three months, and it must put your money in a bank account that earns interest for you. On 04/16/24, during the group meeting with residents who have previously attended resident council meetings, R18, R19, R34 and R38 did not know how much money they currently have in their accounts. R18, R19, R34 and R38 stated they have not received any type of account balance statement for several months. On 04/16/24 at 10:55 AM, R18 stated, The last time I asked what my balance was, it took a while. They (facility staff) had to email someone in the corporate office before they could let me know how much money I have. I go shopping with my sister sometimes, and the last time I asked for my money it ended up taking two weeks. Someone should be able to tell you how much money you have when you have asked. On 04/17/24 at 10:15 AM, V1 (Administrator in Training) could not provide a current financial statement balance for any resident of the facility. V1 stated, I haven't been figuring the quarterly statements. I wasn't aware that I was supposed to be keeping them current manually. V1 verified that the facility currently manages funds for all the residents, and all residents have not received a financial statement since last year in 2023. The Center for Medicare and Medicaid Services Form 671 titled 'Long term Care Facility Application for Medicare and Medicaid,' dated 04/16/24 and signed by V1 (Administrator in Training) documents 43 residents currently reside in the facility. Page 1 of 17 146020 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure the results of any surveys, certifications, and complaint investigations conducted during the past three years were available for review. This has the potential to affect all 43 residents currently residing in the facility. Residents Affected - Many Findings include: On 04/16/24, during the group meeting with residents who have previously attended Resident Council meetings, R18, R19, R34 and R38 did not know where in the facility to access the facility's previous annual and complaint survey results and did not know that all (State Agency) survey results were accessible. On 04/16/23 at 11:20 AM, a binder titled, 'Certification Survey Results for Public Inspection' was located on an end table near the entrance to the building in the front hallway across from V1 (Administrator in Training) and V2's (Director of Nursing) offices. At this same time, V1 verified the most recent survey results that the survey binder contained were from a complaint investigation conducted on 01/18/2023. V1 stated, I haven't kept it current, and confirmed the facility's 2023 annual survey and additional complaint investigations conducted after 01/18/23 were not included in the binder. The Center for Medicare and Medicaid Services Form 671 titled 'Long term Care Facility Application for Medicare and Medicaid,' dated 04/16/24 and signed by V1 (Administrator in Training) documents 43 residents currently reside in the facility. 146020 Page 2 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) level I re-screening for one of two residents (R4) reviewed for PASARR screening, in the sample of 20. Residents Affected - Few Findings Include: R4's Face sheet documents R4 was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder, Depression, and Post-Traumatic Stress Disorder. R4's OBRA-I (Omnibus Budget Reconciliation Act) Initial Screen (dated 01/22/20) documents R4 was evaluated on 01/20/20. This form documents, Screening is valid for 90 days from date of screening. R4's current medical record does not include a PASARR (Preadmission Screening and Resident Review) level I, or any additional screenings. On 04/17/24 at 11:05 AM, V1 (Administrator in Training) stated that she cannot provide a copy of any screening in addition to the OBRA-I Initial Screen conducted on 01/20/20 for R4. 146020 Page 3 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

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 observation, interview and record review the facility failed to update a plan of care for three residents (R4, R32 and R35) of three residents reviewed for care plan accuracy, in a sample of 20. Residents Affected - Few Findings Include: The facility's policy, Comprehensive Care Planning, dated (revised) 7/20/22 directs staff, It is the (facility) policy to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care .The care plan shall be reviewed and revised as necessary to reflect the resident's current medical, nursing and mental and psychological needs as identified. 1. R4's Laboratory Specimen Result form (dated 04/08/24) documents R4's urine specimen collected on 04/02/24 contained substantial growth for VRE (Vancomycin Resistant Enterococcus). R4's current Physician's Orders document the following medication order: Ceftriaxone Injection 500 milligrams inject 500 milligrams intramuscularly one time a day for VRE (Vancomycin Resistant Enterococcus)/UTI (Urinary Tract Infection). R4's Progress Notes (dated 04/15/24) documents the following: Continues on IM (intramuscular) Rocephin due to VRE (Vancomycin Resistant Enterococcus). No adverse reactions. Foley catheter patent draining clear yellow urine, no sediment or blood noted. No complaint of abdominal discomfort. Fluids encouraged and taken well. Contact isolation maintained. R4's current care plan has no mention of Contact Isolation Precautions in place for VRE (Vancomycin Resistant Enterococcus) in his urine. On 04/17/24 at 10:33 AM, V7 (Licensed Practical Nurse/Care Plan Coordinator) confirmed that R4's care plan was not revised to reflect R4's Contact Isolation Precautions status. 2. On 4/15/24 at 9:30 A.M., R32 was in bed sleeping. 2-3 plus edema was noted to R32's bilateral lower legs and feet. R32's current Physician Order Sheet (April 2024) includes the following diagnosis and orders: Edema; Lasix Oral Tablet 20 MG (milligrams), Give 20 mg by mouth one time a day for BLE (Bilateral Lower Extremities) swelling. R32's current Care Plan, dated 2/28/24 does not address the current edema in R32's bilateral lower legs. On 4/17/24 at 12:51 P.M., V7/Care Plan Coordinator verified that R32's care plan did not address R32's edema. 3. R35's Care plan, dated 8/7/2023, documents the following: R35 has a noted stage 2 (pressure ulcer) to right gluteal fold, measures 2.5 centimeters (cm) x 1.5cm x 0.2cm. 146020 Page 4 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0657 R35's Treatment sheet, dated 2/1/2024, does not document that R35 has an open area on right gluteal fold. Level of Harm - Minimal harm or potential for actual harm R35's Treatment sheet, dated 3/1/2024 through 3/31/2024, does not document that R35 has an open area on the right gluteal fold. Residents Affected - Few R35's Skin Only Evaluation, dated 3/19/2024, documents, Note, R35 's previously had MASD (Moisture Associated Skin Damage) area is resolved. Skin: Does resident have current skin issues-No On 4/15/2024 at 10:15 AM, R35 observation was done. There were no open areas to right gluteal fold. On 4/18/2024 at 8:30AM V2/DON (Director of Nurses) stated,R35 does not have any skin issues or open areas at this time. 146020 Page 5 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation, interview and record review the facility failed to implement interventions to reduce a resident's risk of a fall (R32, R41) and failed to provide adequate supervision to prevent falls for resident (R23), for three of three residents reviewed for falls in a sample of 20. FINDINGS INCLUDE: The facility policy, Fall Prevention dated (revised) 11/10/18 directs staff, To provide for resident safety and to minimize injuries related to falls. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident. Appropriate interventions will be implemented for residents determined to be at high risk for falls. 1. R32's current Physician Order Sheet, dated April 2024 documents that R32 was admitted to the facility on [DATE] with the following diagnoses: Anxiety Disorder, Osteoarthritis, Spinal Stenosis, Altered Mental Status and Alzheimer's Disease. R32's current Fall Risk Evaluation, dated 2/29/24 documents R32 is at risk for falls. R32's current Care Plan, dated 2/28/24 identifies the following Focus Areas and Interventions: Resident has risk factors that require monitoring and intervention to reduce potential for self injury and fall. Interventions: Keep call light within reach at all times. Answer promptly and notify resident that help is coming. On 4/15/24 at 9:30 A.M., (R32) was asleep in bed. No call light was near (R32). (R32's) call light was on the floor, under the bed. At that time, V6/Registered Nurse confirmed that R32 was high risk for falls and R32's call light was not in reach. 2. R41's current Physician Order Sheet, dated April 2024 documents that R41 was admitted to the facility on [DATE] with the following diagnoses: Dementia, Cerebral Infarction, Neurocognitive Disorder with Lewy Bodies and Depression. R41's current Fall Risk Evaluation, dated 4/8/24 documents R41 is at risk for falls. R41's current Care Plan, dated 7/14/23 identifies the following Focus Areas and Interventions: (R41) is high risk for falls. Interventions: Uses a pad alarm at all times. Staff to check function and placement every shift and as needed. On 04/15/24 9:50 A.M., (R41) was in his room, in a wheelchair. A blue chair alarm was hanging from the back of (R41's) wheelchair. The chair alarm was not currently connected to a power source and was not functioning. At 9:53 A.M., V6/Registered Nurse (RN) verified R41's alarm was not connected and functioning. 3. On 4/15/24 at 11:08 AM, R23 was in her room lying in bed. R23's high-back wheelchair was placed next to her bed and a mechanical lift sling was sitting in the chair. 146020 Page 6 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R23's Minimum Data Set assessment, dated 6/28/23, documents R23 requires Substantial/Maximal Assistance when sitting to lying: The ability to move from sitting on side of bed to lying flat on the bed. This assessment defines substantial/maximal assistance as Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R23's current care plan, dated 2/6/24, documents R23 has diagnoses of Unsteadiness on Feet, Reduced Mobility, Abnormalities of Gait, and Dementia. This same care plan documents (R23) is at risk for falls. She has a fall assessment score of 13 and is at high risk. (R23) requires extensive assist with ADL's (Activities of Daily Living) and mobility. (R23) has poor safety awareness and poor memory. R23's progress notes dated 6/27/2023 at 6:48 PM documents (R23) appears to have experienced an alleged Intentional Change in Plane, witnessed without head involvement. Evaluation of the resident and event occurred on or about 6/27/2023 at 6:35 PM. Just prior to/at the time of the event (R23) appears to have been being assisted to bed. Witness to the event includes: (V14, Certified Nursing Assistant, CNA). Was sitting on the bed then went down to the floor on her knees. Staff's immediate response is noted as: Request help for other staff and assess resident. Enabler in use included: W/C (wheelchair), (sit to stand lift device). Management/Intervention: Facility staff actions/interventions and response at time of the event includes: Request help from other staff. Assess resident. R23's Fall investigation note, dated 6/27/24, documents While resident was being assisted to bed, she leaned forward while sitting on the edge of the bed and fell to her knees. Resident unable to give description. On 4/17/24 at 1:55 PM, CNA V14 stated I don't remember that fall (6/27/24) at all for (R23). There should always be two people assisting with lifts. I don't remember when (R23) changed from a (sit to stand lift) to a (mechanical lift). She is a (mechanical lift) now. When she used the (sit to stand lift) you would need two people, especially with her because she would need someone to support her back when she's upright. She is not safe to sit unsupported. On 4/18/24 at 8:45 AM, V3 (Assistant Director of Nursing) stated I do not have a witness statement from this event. I know the new intervention after this fall was to change her to a (Mechanical lift) instead of the (sit to stand) lift. On 4/18/24 at 8:50 AM, V2 (Director of Nursing) stated We put the request for staff to ask for help as an intervention on her report. There should be two staff in there when using a lift device, that is policy. (V14) was the only one in there according to the report, (V14) was the only witness to the fall. It's policy to have two staff with lifts and should have been two staff in there at the time. I don't see where I have any witness statements from the event. V2 then confirmed if someone is being transferred to bed with a lift they should wait in the room until the resident is laying down and that (R23's) fall investigation list only one CNA as a witness to the fall. 146020 Page 7 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure an indwelling urinary catheter was secured with a securement device for one of three residents (R33) reviewed for indwelling urinary catheters in the sample of 20. Findings Include: The facility's Catheterizations (Indwelling) Catheter Insertion policy (revised 02/2018) documents: Secure the catheter to the thigh and attach drainage collection unit. R33's current medical record documents R33's diagnoses to include: Neuromuscular Dysfunction of Bladder. On 04/15/24 at 10:30 AM, R33 was reclined in a recliner operating her tablet. R33 stated she currently has an indwelling urinary catheter. R33's indwelling urinary catheter drainage bag was secured to the lower aspect of her wheelchair and was draining clear, yellow urine. On 04/17/24 at 11:30 AM, R33 was lying in bed covered with a blanket. V16 and V17 (Certified Nursing Assistants) entered R33's room to provide indwelling urinary catheter care. V16 and V17 applied gloves, uncovered R33 and assisted her to remove her pants. An indwelling urinary catheter in place, and R33's catheter was not secured with any type of securement device. V17 confirmed that R33's catheter was not secured and stated, We usually have them (indwelling catheter) secured in a device that is stuck on her leg. She should have one in place to hold her catheter. On 04/17/24 at 02:05 PM, V2 (Director of Nursing) stated all indwelling urinary catheters should be secured with a securement device. 146020 Page 8 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop a dementia plan of care for one of three residents (R32) reviewed for dementia care, in the sample of 20. Residents Affected - Few Findings Include: R32's electronic diagnoses dated 3/6/24, document that R32 has a diagnosis of Alzheimer's Dementia. R32's current Care Plan, dated 2/28/24, has no documentation of a comprehensive care plan addressing R32's diagnosis of Alzheimer's Dementia. On 4/17/24 at 12:56 P.M., V17/Care Plan Coordinator) confirmed there is no dementia plan of care for R32. 146020 Page 9 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview and record review the facility failed to ensure the physician evaluated and documented the rationale for the continued use of a PRN (as needed) psychotropic medication for one of three residents (R24) in a sample of 20. FINDINGS INCLUDE: The facility policy, Psychotropic Medication Policy, dated (revised) 6/17/22 directs staff, It is the policy of this facility that residents shall not be given unnecessary drugs. Residents must not have PRN orders for psychotropic medications unless the medication is necessary to treat a diagnosed specific condition. PRN orders for antipsychotic medications only, Time Limitation: 14 days, Exception: None, If the attending physician or prescribing practitioner wishes to write a new order for the PRN antipsychotic, the attending physician or prescribing practitioner must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. R24's physician order, dated 3/8/24 documents, Haldol (antipsychotic medication) IM (Intramuscular) every 12 hours, as needed every 12 hours for Anxiety Disorder. A second clarification physician order for Haldol is dated 3/15/24. R24's current Physician Order Visit note is dated 11/16/2023. No further physician visit notes are available on R24's chart. On 4/17/24 at 10:54 A.M., V7/Care Plan Coordinator verified the missing physician evaluation and documentation for the continues use of (R24's) antipsychotic medication. V7/Care Plan Coordinator stated, (R24) has not been seen by her physician since November 2023. 146020 Page 10 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0773 Level of Harm - Minimal harm or potential for actual harm Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on interview and record review, the facility failed to ensure physician orders were implemented for laboratory tests for one of one resident (R33) reviewed for Insulin in the sample of 20. Residents Affected - Few Findings Include: R33's current Physician's Orders document the following medication order: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 35 unit subcutaneously two times a day related to Type 2 Diabetes Mellitus without Complications. R33's current Physician's Orders document the following order: Hemoglobin A1C every 3 Months. R33's medical record does not document any Hemoglobin A1C results since her date of admission to the facility (7/12/23). On 04/17/24 11:15 AM, V2 (Director of Nursing) stated a Hemoglobin A1C has not been completed on R33 since she was admitted to the facility, It was missed. We should have been monitoring this. 146020 Page 11 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

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 ensure facility staff had hair and facial hair fully restrained during food production and clean-up activities. This failure has the potential to affect all 43 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Personal Hygiene and Dress Code, dated (revised) 10/16 directs staff, It is the policy of (facility) that the Food Service Employees adhere to the facility's dress code that will ensure safe, sanitary meal production and service and presents a professional appearance. Food Service staff involved in food production and clean-up will adhere to the department dress code that includes: Hair net or appropriate hair coverings, including facial hair covering, while involved in food production and clean-up activities. On 4/15/24 at 9:01 A.M., V8/Dietary Manger, V9/Cook, V10/Dietary Aide, V11/Dishwasher and V12/Maintenance Director were in the facility kitchen. V9/Cook was cooking food over the kitchen stove. V10/Dietary Aide was stacking clean, plates and cups, V11/Dishwasher was washing the morning meal dishes and V12/Maintenance Director was leaned over the kitchen stove, removing screens above the stove. At that time, V8, V9, and V10's hair was only partially restrained with a hair restraint. Large strands of hair were unrestrained on the tops, sides and backs of each employee's head. V11/Dishwasher had on a ball cap that left the sides and back of his hair unrestrained. V11 had no hair restraint covering his beard. V12/Maintenance Director was also wearing only a ball cap that left the front, sides and back of his hair unrestrained. V12 had no hair restraint covering his beard. On 4/15/24 at 9:35 A.M., V10/Dietary Manager verified that all staff facility staff should have all hair restrained while in the facility kitchen. The CMS Long- Term Care Application For Medicare and Medicaid form, dated 4/15/2024 and signed by V1/Administrator, documents 43 residents currently reside in the facility. 146020 Page 12 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant Organisms. This failure has the potential to affect all 43 residents currently residing in the facility. Residents Affected - Many Findings include: The facility's Transmission Based Precautions Policy (revised 12/14/09) documents the following: Contact Precautions: Are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn residents, bathe residents, or also can occur between two residents, with one serving as the source of infectious microorganisms and the other as a susceptible host. Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object usually inanimate in the resident's environment. Contact Precautions apply to specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. The facility's Contact Precautions policy (revised 12/09) documents the following: In addition to Standard Precautions, use Contact Precautions, or the equivalent for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident care activities that require touching the residents dry skin) or indirect contact (touching with environmental surfaces or resident care items in the residents environment). This same policy documents, In addition to wearing gloves as outlined under Standard Precautions, wear gloves when entering the room. In addition to wearing a gown as outlined under Standard Precautions, wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the residents room. The facility's Enhanced Barrier Precautions policy (dated 07/13/23) documents, Enhanced Barrier Precautions require use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP (Enhanced Barrier Precautions) is primarily intended to use for care that occurs within a resident's room, when high-contact resident care activities are bundled together. Outside of a resident's room, EBP should be followed when performing transfers in the shower/assisting with shower and when assisting a resident with toileting in common restrooms. High-contact care activities include: Dressing, Bathing/Showering, Transfers, Hygiene, Changing linens, Changing briefs or toileting, Caring for medical devices (i.e. central lines, urinary catheters, feeding tubes, tracheostomies, drainage tubes, ports), Wound care (pressure ulcers, diabetic ulcers, unhealed surgical wounds, chronic venous stasis wounds), and Skilled Therapies. 1. On 04/15/24 at 10:55 AM, R4 was sitting in a wheelchair in his room drawing a picture. R4 stated he currently has an indwelling urinary catheter and facility staff cleanses his catheter daily, They put on gloves before cleaning my catheter. R4 stated that facility staff members have not been wearing gowns when assisting him with cares recently. R4's Laboratory Specimen Result form (dated 04/08/24) documents R4's urine specimen collected on 146020 Page 13 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0880 04/02/24 contained substantial growth for VRE (Vancomycin Resistant Enterococcus). Level of Harm - Minimal harm or potential for actual harm R4's current Physician's Orders document the following medication order: Ceftriaxone Injection 500 milligrams inject 500 milligrams intramuscularly one time a day for VRE (Vancomycin Resistant Enterococcus)/UTI (Urinary Tract Infection). Residents Affected - Many R4's Progress Notes (dated 04/15/24) documents the following: Continues on IM (intramuscular) Rocephin due to VRE (Vancomycin Resistant Enterococcus). No adverse reactions. Foley catheter patent draining clear yellow urine, no sediment or blood noted. No complaint of abdominal discomfort. Fluids encouraged and taken well. Contact isolation maintained. On 04/15/24 at 11:05 AM, V15 (Certified Nursing Assistant) stated she is one of the Certified Nursing Assistants assigned to work the 200 hall for the day, and no resident residing in the 200 hall was currently on isolation precautions. On 04/15/23 at 10:30 AM, no signage for isolation precautions was posted on R4's door, and no bin containing PPE (Personal Protective Equipment) was present near the entry to R4's room or inside his room. On 04/15/24 at 11:20 AM, V6 (Registered Nurse) stated that R4 is currently on Contact Isolation Precautions for VRE of his urine, and confirmed there is no signage posted alerting individuals to R4's isolation precautions. V6 also confirmed there is no availability of PPE for staff to access prior to entering R4's room. On 04/15/24 at 01:00 PM, R4 was propelling in the hallway toward his room. R4's indwelling urinary drainage bag was sitting inside of a dignity bag secured to the lower aspect of his wheelchair. No signage was posted on R4's door indicating any type of Isolation Precautions, and PPE was not available to access at the entrance to R4's room. On 04/15/24 at 01:38 PM, V15 (Certified Nursing Assistant) entered R4's room to empty his indwelling urinary catheter bag. V15 washed her hands, applied gloves and removed R4's urinary catheter drainage bag from the dignity bag secured to the lower aspect of his wheelchair. V15 opened the valve on the drainage bag and drained approximately 650 milliliters of dark yellow urine into a graduated cylinder. V15 then emptied the cylinder full of urine into R4's toilet. V15 did not apply a gown prior to emptying R4's urinary drainage bag or handling the graduated cylinder full of urine. V15 then confirmed her previous statement indicating no residents in the 200 hall are currently in isolation precautions. On 04/16/24 at 10:05 AM, V6 (Registered Nurse) was observed hanging signage on the door to R4's room indicating Contact Isolation Precautions are currently in place. V6 also positioned a small plastic bin containing PPE (Personal Protective Equipment) in the hallway near the entrance to R4's room. V6 then stated that although R4 has been in contact isolation precautions since 04/08/24, she was just now hanging the required postings and placing the appropriate PPE required for individuals prior to entering R4's room. On 04/16/24 at 12:45 PM, V1 (Administrator in Training) stated that all staff can go anywhere throughout the building to provide assistance to the residents, Some residents require two assist, which means that two staff can assist with providing care no matter which hall they have been assigned to for the day. The CNAs (Certified nursing Assistants) are basically assigned a hallway to ensure 146020 Page 14 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many required charting is completed. Staff can go to the dining room during meals to assist if and when needed, and they can also go to the activity room when a resident needs help. For first and second shift, we like to run four to five CNAs ideally. If we have extra (5th) then they are the floater between both halls. Two CNAs on each hall typically. They answer all call lights, doesn't matter what hall. They work together. 2. On 04/15/24 at 10:30 AM, R33 was reclined in a recliner operating her tablet. An indwelling urinary catheter drainage bag was secured to the lower aspect of R33's wheelchair and was draining clear, yellow urine. R33 stated facility staff provide daily cares to her indwelling urinary catheter. No signage for Enhanced Barrier Precautions was posted on R33's door, and no PPE supplies were available for access near the entrance to R33's room. R33 stated staff wear gloves when providing cares for her indwelling urinary catheter, but staff have not been wearing gowns. R33's Current Physician's Orders document the following: Catheter care every shift. Catheter output every shift for output. These orders do not document any type of order for Enhanced Barrier Precautions. R33's current care plan has no mention of Enhanced Barrier Precautions currently in place. On 04/15/24 at 11:20 AM, V6 (Registered Nurse) verified there is no sign for Enhanced Barrier Precautions posted on R33's door, or bin containing PPE supplies near the entrance to the doorway. V6 stated, We don't have any residents in the building on Enhanced Barrier Precautions. 3. R35's Physician Order Sheet dated, 4/1/2024, documents, Catheter care change monthly, 16 French Caude and as needed. R35's Care plan, dated 2/1/2024, documents, R35 has a 16 French with 10 ML (milliliter) balloon (urinary) catheter. On 4/15/2024 at 10 AM R35 was laying in R35's bed resting. R35's urinary catheter and tubing was securely hanging from the bed rail. R35 was turned and repositioned by staff who were not gowned or gloved. Signage for the enhanced barrier precautions was not on R35's door. On 4/17/2024 at 10:30 AM V3/ADON (Assistant Director of Nursing) stated, We were not aware of the Enhance barrier precautions until yesterday. I did not get the memo from back in January that corporate sent to us. The company had all their computers hacked and none of the emails that were sent out to the facilities were received from corporate. We placed the residents that have catheters and wounds in enhance barrier precautions, just today. All staff were in-serviced regarding the enhanced barrier precautions, and they understand what needs to be done when caring for R35. 4. R42's Physician Order Sheet, dated 4/15/24, documents R42 has an order for 20 French suprapubic catheter (urinary) 25 milliliter balloon. Change monthly and as needed one time a day every one month starting on the 3rd for one day(s) related to Calculus of Kidney with Calculus of Ureter and as needed. On 4/15/24 at 11:15 AM, R42 was sitting in his room sitting in recliner with his eyes closed. R42's door or room did not contain any signs for Enhanced Barrier Precautions or Personal Protective 146020 Page 15 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0880 Equipment (PPE) to wear into the room for advanced barrier precautions. Level of Harm - Minimal harm or potential for actual harm On 4/16/24 at 9:38 AM and 4/17/24 at 1:40 PM, R42 was observed in his room sleeping in a chair. R42's room did not contain any signs or PPE to alert that R42 is in any type of isolation. Residents Affected - Many On 4/17/24 at 1:50 PM, V18 (Licensed Practical Nurse) confirmed that R18 has a supra-pubic urinary catheter and is not in any type of isolation. The Center for Medicare and Medicaid Services Form 671 titled 'Long term Care Facility Application for Medicare and Medicaid,' dated 04/16/24 and signed by V1 (Administrator in Training) documents 43 residents currently reside in the facility. 146020 Page 16 of 17 146020 04/18/2024 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on Interview and Record Review, the facility failed to provide a minimum of twelve hours of nurse aide training over a twelve month period. This failure has the potential to affect all 43 residents in the facility. Residents Affected - Many Findings include: The facility's Certified Nursing Assistant (CNA) training folder, provided by V3 ADON (Assistant Director of Nursing) does not contain the required minimum of twelve hours of CNA training for the past year for CNA's currently working in the facility. On 4/18/24 at 8:25 AM, V3 (ADON) stated I am not able to find any of the CNA training for the last year. I only have January 2024 forward and that is not the twelve hours. I do not have proof that all CNA's were trained at least 12 hours and that it included Dementia and Abuse training. The Center for Medicare and Medicaid Services Form 671 titled 'Long term Care Facility Application for Medicare and Medicaid,' dated 04/16/24 and signed by V1 (Administrator in Training) documents 43 residents currently reside in the facility. 146020 Page 17 of 17