Inspection·January 28, 2025

F 0679 Provide activities to meet all resident's needs. 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 provide and implement activities to meet the interests and needs of the residents. This failure affects five (R1, R2, R3, R4, and R5) of five residents reviewed for activities on the sample list of five. Residents Affected - Some Findings Include: On 1/28/25 intermittent observations were done between 10:05am and 2:20pm. R1 through R5 were observed between 10:05am and 10:20am sitting at tables in the dining/activity area participating in various activities (reading, puzzles, coloring, and folding). At 2:15pm, R2, R3, and R5 were observed sitting at the same tables they had been observed at 10:05am and 12:26pm in the dining/activity area with their empty lunch dishes still on the table. Residents were not observed in any group activities during these observations and no other individual activities observed while on the unit. There is no documentation in the Memory Care Unit Activity Binder for R1, R2, R3, R4, or R5 for the month of January 2025. This binder contains a resident specific Enrichment Information Sheet Memory Lane-Fitness for the Mind: which lists goals, key interests, focus of programming and participation barriers. This binder also contains Daily Enrichment Program Documentation Form containing Activities List and Participation Level. This form is for staff to document what activities each individual resident participated in daily. There is no activity calendar posted or available on the unit. 1. R1's Face Sheet documents R1 has diagnoses including Dementia and Anxiety. R1's Comprehensive assessment dated [DATE] documents R1 is moderately cognitively impaired. Further documents the following related to activities: How important is it to you to do your favorite activities-Very Important. This same record documents the following as activities as very important/important to R1: do your favorite activities; get outside to fresh air when the weather is good; participate in religious services or practices; having books, newspapers, and magazines to read; and listen to music you like. R1's Care Plan dated 1/22/24 documents the following: R1 has recently been admitted to the Memory Lane Fitness for the Mind Program. R1 will participate in three group activities daily. Encourage R1 to attend participation in exercise group, trivia, church services and outdoor activities when weather permits. R1's Progress Notes dated 1/13/25, 1/14/25 and 1/23/25 documents R1 having behaviors towards R4 (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 01/28/2025 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)