Health inspection·June 3, 2025

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide a functioning bathroom nurse call light system. This failure has the potential to affect all 44 current facility residents. Residents Affected - Many Findings include: The facility Concern Form, dated 3/17/2025 documents, Nature of concern: Call lights not working. The facility form Resident Council Minutes, dated April 2025 documents, Maintenance: Call lights not working. The facility form, Resident Council Minutes, dated May 2025 documents, Call lights not working. The facility Concern Form, dated 6/2/25 documents, Nature of concern: Call lights- bathroom (s), ongoing. On 6/2/25 at 10:51 A.M. an observation of R2's bathroom (nurse) call (system) button on the wall in (R2)'s bathroom, showed a red button with no string attached for R2 to pull. At that time the (nurse) call light button was activated. No light activated above R2's room door, or audible sound was heard. At that time, R2 stated, I have complained about this (broken system) many times to (V1/Administrator). It's been about a year. All they say is they are working on it.' On 6/2/25 at 10:54 A.M. an observation of the facility 100 Hall nurse's station call board shows no light activated for (R2)'s room, to notify staff that R2 would need assistance in the bathroom. The observation was confirmed with V8/Licensed Practical Nurse (LPN). At that time V8/LPN stated the (nurse) call system in the resident's bathrooms have been broken for a long time. On 6/2/25 at 11:00 A.M., R1 stated the call light in her bathroom has been down for months. R1 states she and her son have both been to V1/Administrator many times in the past few months and all they (are told) is that it is being worked on. On 6/2/25 at 11:03 A.M. the (nurse) call button was pushed in (R1)'s bathroom. No light outside of (R1)'s room door activated. No audible sound was heard outside of (R1)'s room door. An observation of the facility 200 Hall wing (nurse) call light (system) board shows no light on for (R1)'s room, to notify staff that R1 would need assistance in the bathroom. The observation was verified with V11/Certified Nursing Assistant (CNA). At that time V11/CNA stated that the facility nurse call system in resident's bathrooms has been down for many months. Page 1 of 5 146020 146020 06/03/2025 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 6/2/25 at 11:11 A.M., the (nurse call) system was activated in R3's bathroom. No light above (R3)'s door activated, and no sound was audible to alert staff. The nurse call system did not activate at the 100 Hall nurse's station. Verified with V9/Registered Nurse who states the nurse call light system is not working. On 6/2/25 at 11:22 A.M., V7/Maintenance Director stated he has been an employee of the facility since February 2025. V7 states the (nurse) call system has been down as long as he has been here. V7 states (the facility) has had a local company out many times to work on the system, but it always fails again. V7 states the circuit board that operates the system has no parts available as the system is outdated. V7 states someone in the past has attempted to rig the system back together, but the system always fails again. V7 states V1/Administrator is aware of the situation. V7 states the (facility) corporate management staff is aware of the situation and three bids were obtained in May 2025 for the installation of a new system. V7 states he is unsure if the bids have been accepted and when the work will start on the new system. On 6/2/25 at 11:24 A.M., V1 Administartor confirmed the bathroom (nurse) call light system throughout the entire facility was not working. V1 states the system has been down since at least early January (2025). V1 states a local company has been out multiple times to look at the system, but they are unable to get it operational. V1 states corporate staff were made aware of the situation on 1/8/25. V1 states on 5/22/25 Regional Corporate staff were given quotes to review for the replacement of the call system. V1 confirms that she is unsure when the facility bathroom nurse call system will be replaced and functioning. The facility Midnight Census Report dated 6/2/25 and provided by V1/Administrator documents 44 residents currently reside in the facility. 146020 Page 2 of 5 146020 06/03/2025 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a functioning nurse call system in resident bathrooms for all facility residents. This failure resulted in four of four residents (R1, R2, R3 and R4) expressing fear and anxiety during toileting in their rooms due to a non-functioning nurse call system. Residents Affected - Some Findings include: The facility policy, Call Lights, dated (revised) 2/2/18 documents, Purpose: To respond to resident's requests and needs in a timely and courteous manner. Resident call lights will be answered in (a) timely manner. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. Bathroom lights will be viewed as emergencies and immediate attention given. Call bell system defects will be reported promptly to the Maintenance Director for servicing. 1.) R1's facility admission Record form documents R1's medical diagnoses as: Hemiplegia and Hemiparesis Following Cerebral Infarction; Fibromyalgia, Osteoarthritis, Cerebral Infarction, Bursitis, Pain and Chronic Kidney Disease (Severe). R1's current Minimum Data Set Assessment, dated April 4, 2025, documents, Section C-Cognitive Patterns (Brief Interview for Mental Status) as 14:15 (cognitively intact). This same form documents, Section GG-Functional Abilities Toileting as 01 (dependent). R1's current Care Plan includes the following Focus area: (R1) is at risk for falls. Also included is the following Interventions: Be sure (R1)'s call light is within reach and encourage (R1) to use it for assistance as needed. (R1) needs prompt response to all requests for assistance. On 6/2/2025 at 11:00 A.M., R1 stated the call light in her bathroom has been down for months. R1 states she has waited anywhere from 15 to 30 minutes for staff to come help her off the toilet. R1 states she is totally dependent on staff in the bathroom. R1 states the facility just gave her a bell to ring while she is in the bathroom [ROOM NUMBER]- 3 weeks ago. R1 states a few weeks ago staff placed her on the toilet and left her with a bell. R1 states the bell slipped from her hand and she had no way to notify staff she needed assistance. R1 states she sat on toilet for 30 minutes waiting. R1 states, It really bothers me. It makes me very nervous and fearful when I need to use the toilet. I am completely helpless and if I fell, I would have to lay there. R1 states she and her son have both been to V1/Administrator many times in the past few months and all they (are told) is that it is being worked on. On 6/2/25 at 11:03 A.M. the (nurse) call button was pushed in (R1)'s bathroom. No light outside of (R1)'s room door activated. No audible sound was heard outside of (R1)'s room door. An observation of the facility 200 Hall wing (nurse) call light (system) board shows no light on for (R1)'s room, to notify staff that R1 would need assistance in the bathroom. The observation was verified with V11/Certified Nursing Assistance (CNA). At that time V11/CNA stated that the facility nurse call system in resident's bathrooms had been down for many months. V11/CNA states she had observed (V7/Maintenance Director) working on the system, but the nurse call system would continue to malfunction. 146020 Page 3 of 5 146020 06/03/2025 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0919 Level of Harm - Actual harm Residents Affected - Some 2.) R2's facility admission Record form documents R2's medical diagnoses as: Spinal Stenosis, Lumbosacral Region; Type 2 Diabetes Mellitus with Diabetic Neuropathy; Chronic Pain Syndrome; Spondylosis; History of Fracture of the Pelvis; Low Back Pain; Primary Generalized Osteoarthritis. R2's current Minimum Data Set Assessment, dated May 14, 2025, documents, Section C-Cognitive Patterns (Brief Interview for Mental Status) as 15:15 (cognitively intact). This same form documents, Section GG-Functional Abilities Toileting as 03 (partial/moderate assist). R2's current Care Plan includes the following Focus area: (R2) is at risk for falls. Also included is the following Interventions: Be sure (R2)'s call light is within reach and encourage (R2) to use it for assistance as needed. (R2) needs prompt response to all requests for assistance. On 6/2/25 at 10:51 A.M. an observation of R2's bathroom (nurse) call (system) button on the wall in (R2)'s bathroom, showed a red button with no string attached for R2 to pull. At that time the (nurse) call light button was activated. No light activated above R2's room door, or audible sound was heard. At that time, R2 stated, I am at risk for falling. I have fallen many times, and I need my walker to ambulate. I fell in the bathroom and my call light wasn't working. I had to yell for help. It took a while for the staff to come. When I am in my bathroom with the door closed, you can't hear a bell ringing or if there aren't any staff outside your door, they can't hear you yell. I have complained about this (broken system) many times to (V1/Administrator). It's been about a year. All they say is they are working on it. I am afraid to go to the bathroom. I have no way to summon staff. On 6/2/25 at 10:54 A.M. an observation of the facility 100 Hall nurse's station call board shows no light activated for (R2)'s room, to notify staff that R2 would need assistance in the bathroom. The observation was confirmed with V8/Licensed Practical Nurse (LPN). At that time V8/LPN stated the (nurse) call system in the resident's bathrooms have been broken for a long time. 3.) R3's facility admission Record form documents R3's medical diagnoses as: Restless Legs Syndrome; Chronic Gout Right Ankle and Foot; Abnormalities of Gait and Mobility; Nocturia; Unsteadiness on Feet; Polyosteoarthritis; Spinal Stenosis; Scoliosis, History of Falling. R3's current Minimum Data Set Assessment, dated May 8, 2025, documents, Section C-Cognitive Patterns (Brief Interview for Mental Status) as 14:15 (cognitively intact). This same form documents, Section GG-Functional Abilities Toileting as 03 (partial/moderate assist). R3's current Care Plan includes the following Focus area: (R3) is at risk for falls. Also included is the following Interventions: Be sure (R3)'s call light is within reach and encourage (R3) to use it for assistance as needed. (R3) needs prompt response to all requests for assistance. On 6/2/25 at 11:11 A.M., R3 stated right now he doesn't think his bathroom (nurse) call light (system) is working. States he wears a whistle around his neck all day and all night to be able to summon help from the staff. States he doesn't feel safe in the bathroom and is afraid to go without the whistle. States he is unsure how long call system has been broken. At that time the (nurse call) system was activated in R3's bathroom. No light above (R3)'s door activated, and no sound was audible to alert staff. The nurse call system did not activate at the 100 Hall nurse's station. Verified with V9/Registered Nurse who states the nurse call light system is not working. 4.) R4's facility admission Record form documents R4's medical diagnoses as: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy; Epilepsy; Lack of Coordination; Pain; Chronic Instability of Right 146020 Page 4 of 5 146020 06/03/2025 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0919 Knee; Rheumatoid Arthritis; Bilateral Primary Osteoarthritis of Knee; Restless Legs Syndrome. Level of Harm - Actual harm R4's current Minimum Data Set Assessment, dated March 11, 2025, documents, Section C-Cognitive Patterns (Brief Interview for Mental Status) as 14:15 (cognitively intact). This same form documents, Section GG-Functional Abilities Toileting as 05 (set up or clean up assistance). Residents Affected - Some R4's current Care Plan includes the following Focus area: (R4) is at risk for falls. Also included is the following Interventions: Be sure (R4)'s call light is within reach and encourage (R4) to use it for assistance as needed. (R4) needs prompt response to all requests for assistance. On 6/3/25 at 8:50 A.M., R4 stated she recalls falling in her bathroom on 4/18/25. States she usually takes self to the bathroom. States call light in bathroom is non-functional. States staff gave her a bell to ring. States she stood from wheelchair, got dizzy, her hand slipped off the assist rail and she fell hard, hitting her head against the wall and her right knee and ended up on buttocks. States she was unable to reach the bell prior to the fall, to ask for assistance or after the fall. States she crawled to the doorway and had to yell for help. States she was hurting really bad and was in a lot of pain and requested to go to the ER (Emergency Room). States she had X-rays and blood work, and doctor was concerned about her right knee. States she received pain medication while in the ER to help with the pain. States she wishes she had a call light with a long cord in her bathroom in case she fell again and landed on floor, at least she could call for help. States she is fearful of using the bathroom now after the fall and is afraid if she fell again, she would break something. At that time an activation of (R4)'s bathroom (nurse) call light (system) was performed. No light above (R4)'s room door activated to alert staff. No audible sound to alert staff was heard. The nurse call system did not activate at the facility 100 Hall Nurse's Station. V9/Registered Nurse verified R4's non functioning bathroom nurse call light system. On 6/3/25 at 11:24 A.M., V1Administartor confirmed the bathroom (nurse) call light system throughout the entire facility was not working. V1/Administrator stated that (R1) and (R1)'s family had come to her and expressed concern with (R1)'s fear of being left on the toilet, due to the non-functioning nurse call system. At that time, V1/Administrator stated she was not aware of R2, R3 and R4's fear and anxiety during toileting in their rooms, due to a non-functioning nurse call system. 146020 Page 5 of 5