Health inspection·November 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to report bed bugs and room change to a resident representative for one (R1) of five residents reviewed for bed bugs in the sample list of five. Findings include: The facility's Transfer of a Resident policy dated 1/11/23 documents Upon need for a room transfer within the facility, staff shall meet and discuss the reasons for transfer. The Social Service Director shall discuss the potential room change with the resident and resident's representative. Form NH-#341 Room/Roommate Change Notification shall be utilized should either party request notification in writing. Transfer of the resident and belongings shall be completed as soon as possible and documented by Social Services. The facility's Change in a Resident's Condition dated December 2002 documents the resident's representative will be notified when there are changes in the resident's physical, mental, or psychosocial status. The (Pest Control Company) Proof of Service dated 11/10/24 documents (R1's former room) was treated for bed bugs with an insecticide. R1's Minimum Data Set, dated [DATE] documents R1 has severe cognitive impairment. R1's undated Face Sheet documents V13 as R1's Family and Emergency Contact. R1's Census documents R1 changed rooms on 11/12/24. There is no documentation in R1's medical record as to why this room change occurred or that bed bugs were found in R1's room. On 11/18/24 at 9:46 AM there were no residents residing in R1's former room. At 9:58 AM R1's current room was observed. On 11/18/24 at 11:16 AM V13 confirmed V13 was not aware that bed bugs were found in R1's room on 11/10/24 and V13 was not aware that R1 changed rooms. On 11/18/24 at 11:45 AM V2 Director of Nursing stated bed bugs were found in R1's room on 11/10/24, and this was the only room affected. V2 stated V2 instructed the staff to move R1 into another room. V2 stated resident families of those affected should have been notified of the bed bugs and room change, and this should be documented in a progress note. V2 confirmed there is no documentation in R1's nursing notes that V13 was notified of the bed bugs and room change. At 1:42 PM V2 confirmed R1's electronic medical record does not contain a Room/Roommate Change Notification form for R1's (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 146076 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 146076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Clinton 1 Park Lane West Clinton, IL 61727 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)