Inspection·June 3, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assisted R1 to bed and then walked through the facility to find staff. V4 stated she walked through the entire facility two times and did not see any staff. V4 stated she finally found one male staff member (unknown) sleeping in a dark area at the end of one hall and then found another staff member, V3 Licensed Practical Nurse (LPN), who attempted to help her find others. V3 and V4 walked around the facility two more times without finding any other staff members. V4 stated she asked V3 LPN to call V2 Director of Nurses (DON) and let him know that staff were not available to meet the needs of the residents. V4 stated as she and V3 walked around the facility they observed many resident call lights on and some residents asleep in their wheelchairs in the common areas. V4 stated when she spoke with V2 DON the next day he told her they have had issues with some of the agency Certified Nursing Assistants (CNAs) they have had working in the building. On 5/27/25 at 2:35 PM V3 LPN confirmed that V4 approached her looking for staff on the night of 5/17/25. Both V3 and V4 searched the building twice and could not find anyone else. V3 confirmed V4 was very upset and worried that there was no one there to care for her mother (R1). V3 stated she reassured V4 that she would be calling V2 DON and letting him know about the situation. V3 stated after V4 left the building V3 found out that R1's assigned aide (unknown) had gone to lunch without telling V3. V3 stated she has had many issues with the agency staff who come to work at the facility. V3 stated the aides will tell charge nurses what they will and won't do and they often have attitudes and don't do the work they are supposed to be doing. V3 stated staff have just left for break and not come back or they don't show up for their shift at all. V3 stated she knows family members of residents see the decline in care and are upset about it and she is frustrated that she is unable to do anything about it. On 6/3/25 at 3:30 PM R1 stated she regularly has issues getting her call light answered in a timely manner. Staff will come in and turn off the call light and say they will be back but then never come back. R1 stated on 5/17/25 when she called her daughter, it was because she was unable to find anyone to help her get ready for bed. 2. R2's Medical Diagnoses List dated June 2025 documents R2 is diagnosed with Diabetes, Anxiety, Major Depression, Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Irritable Bowl Syndrome, Repeated Falls, and Lack of Coordination. R2's Minimum Data Set, dated [DATE] documents R2 has a mild cognitive impairment and requires partial assist for activities of daily living and is independent for most transfers. R2 requires the use of a manual wheelchair for mobility. On 5/30/25 at 3:19 PM R2 stated she has issues getting her call light answered in a timely manner. R2 feels the facility needs more staff especially at night in order to provide better care for the residents. R2 stated she feels the quality of care she receives has gone down in the few months. 3. R5's Medical Diagnoses List dated June 2025 documents R5 is diagnosed with Diabetes, Down Syndrome, Depression, Congestive Heart Failure, Prosthetic Heart Valve, Long Term Anticoagulant Use, and Lack of Coordination. R5's Minimum Data Set, dated documents R5 is 5/1/25 documents R5 is cognitively intact and requires supervision or touching assist for most activities of daily living and transfers. R5 requires the use of a manual wheelchair for mobility. R5's Progress Note dated 5/21/25 documents R5's PT/INR (Prothrombin Time/International Normalized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146076 If continuation sheet Page 2 of 4 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 06/03/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Ratio) results and a physician order to take ten milligrams of Coumadin and recheck PT/INR the following Monday (5/26/25). R5's Progress Note dated 5/29/25 documents R5's PT/INR lab work would be taken on 5/30/25 by outside laboratory. Residents Affected - Some R5's Progress Note dated 5/30/25 documents R5's PT/INR lab work was completed and resulted with a PT of 27.3 and INR of 3.9. Orders were received to hold R5's Coumadin dose for two days and recheck PT/INR on 6/1/25. On 6/3/25 at 3:20 PM R5 stated the facility could use more staff especially at night and the staff often take a long time to answer call lights. Sometimes she waits longer than 30 minutes. R5 confirmed she takes a blood thinner and get blood work done regularly due to her blood thinning medication. R5 confirmed her blood work was delayed last week. 4. R6's Medical Diagnoses List dated June 2025 documents R6 is diagnosed with Congestive Heart Failure, Anxiety, Diabetes, Lack of Coordination, and Atrial Fibrillation. R6's Minimum Data Set, dated [DATE] documents R6 is cognitively intact and requires partial or moderate assist for most activities of daily living and supervision or touching assist for transfers. R6 requires the use of a manual wheelchair for mobility. R6's Progress Note dated 5/21/25 documents R6's PT/INR (Prothrombin Time/International Normalized Ratio) results and a physician order to hold R6's Coumadin dose for one night and recheck PT/INR in one week (5/28/25). R6's Progress Note dated 5/29/25 documents R6's PT/INR lab work would be taken on 5/30/25 by outside laboratory. R6's Progress Note dated 5/30/25 documents R6's PT/INR lab work was completed and resulted with a critical INR of 5.82. Orders were received to hold R6's Coumadin dose, give five milligrams of Vitamin K, and recheck PT/INR on 5/31/25. On 6/3/25 at 3:23 PM R6 stated the facility could use more staff especially at night and the staff often take a long time to answer call lights. Sometimes she waits longer than 30 minutes. R6 stated the week prior (5/28/25) she was told her blood work couldn't be done on time because the facility did not have the testing strips they needed. R6 stated she had to wait two extra days (5/30/25) for the blood test. 5. R7's Medical Diagnoses List dated June 2025 documents R7 is diagnosed with Diabetes, Vascular Dementia, Anxiety, Insomnia, Dysphagia, Difficulty Walking, and Communication Deficit. R7's Minimum Data Set, dated [DATE] documents R7 is cognitively intact and requires moderate or maximal assist for most activities of daily living transfers. R6 requires the use of a manual wheelchair for mobility. On 5/30/25 at 2:50 PM R7 stated the facility could use more staff and she often waits a long time for her call light to be answered. R7 feels the quality of care has gone down. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146076 If continuation sheet Page 3 of 4 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 06/03/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/30/25 at 4:15 PM V2 Director of Nurses confirmed the facility has had to use more agency staff, especially CNAs. V3 confirmed they have had issues with the bad attitudes of agency staff and because they can just go work anywhere it is hard to keep those staff accountable for their actions or lack of actions. V2 acknowledged that this creates a risk for poor quality of resident care. On 6/3/25 at 10:30 AM V7 Registered Nurse stated she has seen an issue with long call light wait times and believes staffing is an issue not because they are short staffed but because the agency staff they have on the schedule usually aren't the best workers and don't do their jobs well. On 6/3/25 at 3:56 PM V2 DON confirmed the facility did not have the PT/INR testing strips they needed to complete physician ordered PT/INR tests. V2 confirmed the staff delayed the tests which were completed 2-3 days after originally ordered. V2 confirmed R6's lab result came back a critical result on 5/30/25. V2 confirmed the facility still does not have the Pt/INR test strips in house but instead are now drawing resident's blood and sending it to the lab in order to complete the PT/INR tests timely. V2 also confirmed the facility has had complaints in Resident Council, with Grievances, and from residents and families concerning ice water not being passed, call lights not answered timely, showers not being done per schedule, and two-hour checks not being completed. V2 confirmed they have had some issues with the quality of work from the agency CNAs that have picked up shifts with the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146076 If continuation sheet Page 4 of 4