Health inspection·February 19, 2025

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, observation, and record review the facility failed to report alleged verbal, mental, and physical abuse to the State Agency for one of three residents (R3) reviewed for abuse in the sample of four. Residents Affected - Few Findings include: The Facility's Abuse Prevention and Reporting-Illinois Policy, revised 10/24/2022, documents, Any allegation of abuse will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. On 2/18/2025 at 9 A.M, R3 stated there was a day when V6 (CNA/Certified Nursing Assistant) was yelling and being loud while she tried to sleep. R3 stated she told V6 to be quiet and V6 called her crazy. R3 stated she told V2 (DON/Director of Nursing) about this. On 2/18/2025 at 9 A.M, R3 stated that the last time she was in the hospital she remembers the day she came back on 2/1/2025, V5 (CNA/Certified Nursing Assistant) was helping her in bed while using the mechanical lift and grabbed her right wrist to put it back in the mechanical lift. R3 stated she felt a jolt of pain in her right shoulder. R3 stated she told V5 that it hurt and yelled out. R3 stated V5 looked at her and turned around facing V6 (CNA/Certified Nursing Assistant) and yelled Did you see anything? Did you see me hurt her? R3 stated V5 then said Is it going to be like this now? I did not hurt you! Why would you say that? R3 stated after that V5 stated You are crazy. R3 stated she told V2 the day after this happened on 2/2/2025. On 2/18/2025 at 3 P.M, V2 stated R3 did report to her that staff were mean to her. On 2/19/2025 at 10:30 A.M, V1 was unable to provide documentation of R3's allegations of potential abuse being reported to the Stated Agency. V1 confirmed R3's allegations of potential abuse were not reported to the State Agency. Page 1 of 3 146020 146020 02/19/2025 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

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 allegations of potential physical, mental, and verbal abuse and ensure the alleged victim was protected from further abuse during the investigation for one of three residents (R3) reviewed for abuse in the sample of four. Residents Affected - Few Findings include: The Facility's Abuse Prevention and Reporting-Illinois, revised 10/24/2022, documents, Employees of this facility who have been accused of abuse, will be removed from the resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse is unsubstantiated. All incidents will be document whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. The appointed investigator will, at minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview able. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse by the accused individual. R3's BIMS (Brief Interview of Mental Status) score from January 27th, 2025, had a score of 15, meaning cognitively intact. On 2/18/2025 at 9 A.M, R3 stated there was a day when V6 (CNA/Certified Nursing Assistant) was yelling and being loud while she tried to sleep. R3 stated she told V6 to be quiet and V6 called her crazy. R3 stated she told V2 (DON/Director of Nursing) about this. On 2/18/2025 at 9 A.M, R3 stated that the last time she was in the hospital she remembers the day she came back on 2/1/2025, V5 (CNA/Certified Nursing Assistant) was helping her in bed while using the mechanical lift and grabbed her right wrist to put it back in the mechanical lift. R3 stated she felt a jolt of pain in her right shoulder. R3 stated she told V5 that it hurt and yelled out. R3 stated V5 looked at her and turned around facing V6 (CNA/Certified Nursing Assistant) and yelled Did you see anything? Did you see me hurt her? R3 stated V5 then said to her Is it going to be like this now? I did not hurt you! Why would you say that? R3 stated after that V5 stated You are crazy. R3 stated she told V2 the next day on 2/2/2025. On 2/19/2025 at 12:40 P.M, V5 stated on 2/1/2025 she remembers being in R3's room with V6 putting R3 in the mechanical lift. V5 stated R3 had her arms outstretched laying back into the mechanical lift. V5 stated she lightly grabbed R3's right wrist to put it safely inside the mechanical lift and R3 shouted Ouch! that hurt!. V5 said she stepped back and looked at V6 and stated Wow! What?! I just lifted your wrist, that's crazy! I barely touched you, and I did not hurt you!. V5 stated she then finished getting R3 back into bed. V5 stated she works all over the building. She does not stay in one hall. On 2/19/2025 at 11 A.M, V6 stated on 2/1/2025 when she was helping V5 transfer R3 back into bed and she remembers R3 shouting to V5 that she hurt her. V6 stated V5 turned around and said did I hurt her? I barely touched her. V6 stated she did not report this incident. V6 also stated she works all over the building. She does not stay in one hall. 146020 Page 2 of 3 146020 02/19/2025 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/18/2025 at 3 P.M, V2 stated she remembers when R3 was back from the hospital on 2/1/25 and she remembers R3 stating that staff were mean, but she did not say who it was or what was said. V2 stated she did report to V1(Administrator) about this information. On 2/19/2025 at 10:20 A.M, V2 stated R3 told her about V6, but she only told her Some CNA's (Certified Nursing Assistants) were being mean V2 stated R3 did not tell her who or what was said. V2 stated she should have investigated R3's allegations, and she should have reported it to V1. On 2/19/2025 at 10:30 A.M, V1 stated she was aware of V6's incident of R3 stating she was being mean to her by V2, but it was not investigated. 146020 Page 3 of 3