Health inspection·March 7, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess a resident for indwelling urinary catheter removal for one of four residents (R45) reviewed for an indwelling urinary catheter in a sample of 28. Findings include: R45's admission Record documents that R45's date of admission to the facility was 11/16/24 and her diagnoses on admission include Unspecified Diastolic Congestive Heart Failure, Hypertension, Hypomagnesium, Arthropathy, Chronic Kidney Disease, and Peripheral Vascular Disease. R45's Minimum Data Set (MDS) assessment documents a Brief Interview for Mental Status (BIMS) score of 12/15, indicating moderate cognitive impairment and documents the use of an indwelling urinary catheter. R45's Physician Order dated 12/10/24 documents R45 has an order for indwelling urinary catheter 18 French with a 30 cubic centimeter (cc) bulb for Neuromuscular Dysfunction of the Bladder. R45's admission bowel and bladder assessment dated [DATE] documents R45 goes to the bathroom with assistance and is usually continent. R45's Electronic Medical Record (EMR) Health Status note dated 12/6/24 documents, resident short of breath O2 (oxygen) on at 3L (liters) per NC (nasal cannula), O2 (oxygen) saturation 85 percent (%). resp (respiration) rate 28. 98.4 T (temperature) unable to obtain a BP (blood pressure) due to severe jerking movements in all upper and lower limbs. EMR also documents R45 was sent to emergency room and admitted to the hospital for Sepsis, Upper Respiratory Infection, and Hypoxia. R45's re-admission bowel and bladder assessment documents R45 returned from hospital on [DATE] with indwelling urinary catheter. On 3/4/25 at 9:42am R45 was sitting in her recliner with an indwelling urinary catheter hanging in a dignity bag on the side of her trash can beside her. R45 stated, I (R45) do not know why I have a catheter, and nobody has talked to me about removing it. R45's EMR has no documentation regarding conversations with R45 to remove the indwelling urinary catheter. On 3/05/25 at 2:00pm, V9/Certified Nursing Assistant stated that R45 did not have a catheter prior to going to the hospital but returned with one. V9 also stated that R45 utilized the bathroom with assistance before hospitalization. On 3/05/25 at 2:48pm V2/Director of Nursing stated, It is the expectation that any resident that did not have an indwelling urinary catheter prior to a hospitalization and returns with one, that the nursing staff get orders for removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146020 If continuation sheet Page 2 of 7 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 146020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to weigh one resident as recommended (R8) of three residents reviewed for weight loss in a total sample of 28. Residents Affected - Few Findings Include: The Facility's Dietary policy dated 10/17/19 documents Residents identified at nutritional risk may be weighed weekly or bi-weekly as per physician order or Interdisciplinary Team recommendation. R12's Medical Record documents R12's weight on 01/09/25 was 237 pounds. R12's Medical Record documents R12's weight on 2/11/25 was 222 pounds. R12's Weight Progress Note dated 2/17/25 documents Dietitian weight review weight 222 pounds (-6.3%) noted in one month. Please change diet to: (due to) weight loss for 1 month resident to have weekly weights (for) four weeks. R12's Medical Record did not have any documentation of any weights after the 2/11/25, 222 pounds weight. On 3/5/25 V8 (Dietary Manager) confirmed that the dietician had recommended weekly weights on 2/17/25 due to weight loss. V8 also confirmed that R12's medical record did not contain any documentation of any weights after 2/11/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146020 If continuation sheet Page 3 of 7 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 146020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, record review and interview the facility failed to assess for the risk of entrapment from side rails for five residents (R3, R8, R11, R31 and R38) of thirteen residents reviewed for siderails in a total sample of 28. Findings Include: The Facility's Side Rails/Bed Rails Policy dated 10/24/22 documents before bed rails are installed, the facility should: Check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible, since most bed rails and mattresses are purchased separately from the bed frame. Rails should be selected and placed to discourage climbing over rails to get in and out of bed, which could lead to falling over bed rails. When installing and using bed rails, the facility should: Ensure that the bed's dimensions are appropriate for the resident; Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed; Install bed rails using the manufacturer's instructions to ensure a proper fit; Inspect and regularly check the mattress and bed rails for area of possible entrapment; Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body. Gaps can be created by movement or compression of the mattress which may be caused by resident weight, resident movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or water bed; Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. R3's Side Rail Assessment dated 1/31/25 documents resident requested for mobility assistance and least restrictive rail device that is appropriate for this resident: quarter rail on the right. On 3/5/25 at 1:00 PM R3's empty bed was made and had the right half side rail in the up position. R8's Side Rail Assessment dated 7/16/24 documents has the resident expressed a desire to have Side Rails/Assist Bar for safety and/or comfort? a. Yes. Bed rail placement recommendations: bilateral. On 3/4/25 at 9:30 AM R8's bed was made, and the full left side rail was in the up position and the right siderail was in the down position. R8 stated that he uses the bed rails while in bed to help turn and position. R11's Side Rail Assessment dated 10/14/24 documents has the resident expressed a desire to have Side Rails/Assist Bar for safety and/or comfort? a. Yes. Bed rail placement recommendations: bilateral. On 3/5/25 at 1:10 PM R11's bed was made with the left side rail in the up position and the right side rail in the down position. R31's Side Rail Assessment dated 8/9/24 documents has the resident expressed a desire to have Side Rails/Assist Bar for safety and/or comfort? A. Yes. Bed rail placement recommendations: Right. On 3/5/25 at 1:12 PM R31's bed was made with the right half side rail in the up position. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146020 If continuation sheet Page 4 of 7 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 146020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473 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 0700 Level of Harm - Minimal harm or potential for actual harm R38's Side Rail Assessment dated 12/16/24 does not document any reasoning for R38's side rails to be in the up position at all. R38's Side Rail Assessment dated 12/16/24 documents least restrictive rail device that is appropriate for this resident: 3. Half rail right. On 3/5/25 at 1:13 PM R38's bed was made with the right half side rail in the down position. Residents Affected - Some On 3/5/25 at 1:15 PM V5 (Certified Nurse Aid) stated that R38 did use a half side rail on the right to help turn herself while in bed. On 3/7/25 at 10:00 AM V1 (Administrator) confirmed that R3, R8, R11, R31 and R38 use side rails to help turn and position themselves in bed. V1 stated the facility had no documentation of any assessment for entrapment with the use of side rails for R3, R8, R11, R31 or R38. We are currently training our new Maintenance Director regarding entrapment assessments that should be done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146020 If continuation sheet Page 5 of 7 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 146020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473 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 - 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for one of five (R47) residents reviewed for unnecessary medications in a sample of 28. Findings include: The facility's policy titled Psychotropic Medication- Gradual Dosage Reduction, revised 2-1-18, documents, Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. R47's admission Record documents R47's date of admission to the facility was 7/14/23 and his diagnoses on admission include Hypertension, Anxiety Disorder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hyperlipidemia, Unspecified Dementia (Unspecified Severity) without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, and Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Posterior Cerebral Artery. R47's Minimum Data Set (MDS) assessment dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 11/15, indicating moderate cognitive impairment and Section E/Behaviors documents no behaviors exhibited. R47's Physician Order dated 11/10/24, documents R47 has an order for Seroquel 25 milligrams/mg (antipsychotic medication) give 0.5 tablet by mouth one time a day for mood disorder related to Vascular Dementia (Moderate) with Mood Disturbance. R47's task- Monitor Behavior symptoms dated 2-4-25 to 2-20-25, documents no behaviors. On 3/4/25 at 10:36am, R47 observed sitting up in wheelchair calmly watching television. On 3/05/25 at 11:50am, R47 observed sitting up in wheelchair in room calmly watching television. On 3/05/25 at 1:00pm, R47 observed sitting up in wheelchair watching television and in no distress. On 3/05/25 at 12:05pm, V7/Licensed Practical Nurse stated that R47 was started on Seroquel shortly after he (R47) admitted to the facility due to aggression. V7 stated R47 was never aggressive toward other residents or staff, just objects in R47's room. V7 also stated that she (V7) has not noticed any aggressive behaviors from him for quite some time and verified that R47 takes Seroquel (antipsychotic medication) for Vascular Dementia with Mood Disturbance. On 3/05/25 at 2:10pm, V2/Director of Nursing stated, R47 has a current order for Seroquel (antipsychotic medication) 25mg (milligrams) take half a tablet by mouth daily for Vascular Dementia with Mood Disturbance. V2 stated, I am not sure of the regulations for antipsychotic medications. V2 also verified that R47 has not had any documented behaviors in his Electronic Medical Record for the past month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146020 If continuation sheet Page 6 of 7 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 146020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to initiate and follow Enhanced Barrier Precautions for one resident of thirteen residents (R26) reviewed for infection control in a sample of 28. Residents Affected - Few Findings include: The facility's policy titled Enhanced Barrier Precautions, review/revised 4/8/24, documents, Purpose: To reduce risk of transmitting multidrug-resistant organisms (MDRO) and targeted MDRO when contact precautions do not apply for residents identified as higher risk. Guidelines: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. R26's admission Record documents that R26's date of admission to the facility was 5/21/24 and his diagnoses on admission include Type 2 Diabetes Mellitus with Unspecified complications, Chronic Obstructive Pulmonary Disease, Generalized Anxiety, Hypertension, and Chronic Viral Hepatitis C. R26's Minimum Data Set (MDS) assessment dated [DATE], documents R26 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition intact and documents R26 has Chronic Viral Hepatitis C. R26's current care plan documents R26 has a need for Enhanced Barrier Precautions related to Hepatitis C. On 3/04/25 at 9:31am, No Enhanced Barrier Precautions (EBP) sign observed, or Personal Protective Equipment (PPE) observed outside or inside R26's room. R26 stated he has Hepatitis C and staff are only wearing gloves when they do cares for him. R26 also stated he has never seen them wear a gown. On 3/05/25 at 12:00pm No EBP sign or PPE outside or inside room observed. On 3/05/25 at 1:00pm, V7/Licensed Practical Nurse stated, EBP is used for residents and staff safety and any resident that has an indwelling medical device such as a catheter should be on EBP or any resident that has a wound or transmissible infection. V7 also stated, I would think R26 would qualify for Enhanced Barriers since he (R26) has Hepatitis. On 3/07/25 at 7:35am, V3/Assistant Director of Nursing stated, EBP is used for wounds, catheters, and requires donning gloves and gown prior to any direct care with a resident. V3 also stated, Infections should be placed on EBP protocol as well. V3 verified that she (V3) considers Viral Hepatitis C as an infection that warrants EBP and verified that R26 currently does not have EBP or PPE in place and he should. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146020 If continuation sheet Page 7 of 7