Inspection·August 18, 2022

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R6's Abuse Investigation dated 6/5/22 documents that V5 (R5 and R6's family member/Healthcare Power of Attorney) reported that R6 slapped R5 on the leg, a couple of times while he was toileting. The Investigation documents that V5 stated, We can tell (R6) is frustrated with (R5) when he (R5) doesn't do something she is asking him to do. R6's Abuse Investigation dated 6/23/22 documents that a CNA (Certified Nursing Assistant) witnessed R6 become frustrated with R5 because he was not responding to her, so she pinched his arm and removed his plate of food from in front of him. R6's Progress Notes dated 6/28/22 at 7:33 AM document R6 Yelling aggressively to husband (R5) at dining room table. (R6) Kicked foot at him (R5) when was slow to respond. R6's Progress Notes dated 7/5/22 at 11:30 PM document, (R6) grabbed husband's (R5) arm aggressively trying to get him to follow her. Nurse asked her (R6) to not grab him (R5) like that, she (R6) stated, 'Just go on and don't worry about it'. On 8/17/22 at 10:30 AM V2 (Interim Director of Nursing) stated, I do believe it (the occurrences between R5 and R6) is abuse, but they are married. On 8/17/22 at 11:20 AM V1 (Administrator) stated Yes these instances (6/3/22, 6/28/22, 7/5/22 and 7/29/22) would be physical and verbal abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146111 If continuation sheet Page 2 of 6 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 146111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report allegations of physical and verbal abuse to the Administrator for one of three residents (R5) reviewed for abuse in a total sample of 15. Findings Include: The Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy dated 2/2018 documents all employees will be trained on, Communication of reports of resident mistreatment, neglect, and/or abuse, including injuries of unknown source and misappropriation of property. This policy also documents, Employees must always report any abuse or suspicion of abuse immediately to the Administrator. R5 and R6's Medical Records document that R5 and R6 are a married couple who were both admitted on [DATE], both with a diagnosis of Alzheimer's Dementia. R5's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, which indicates severe cognitive impairment. R6's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 6/15 , which indicates severe cognitive impairment. R5's Progress Notes (7/29/22 at 11:23 AM) document R5 was noted to have blood running down his arm. These notes document, Wife (R6) said to husband (R5), 'Honey what happened. 'He (R5) replied, 'You scratched me.' Areas measure 0.5 x 0.3 (centimeters), 0.2 x 0.4 (centimeters), and 0.4 (centimeters) x 0.3 (centimeters). R5's Physician Order Sheet dated July 2022 documents Apply TAO (Triple Antibiotic Ointment) to areas daily until healed. R6's Progress Notes document that on 6/3/22 R6 was, Being verbally abusive to her husband (R5). R6's Progress Notes dated 6/28/22 at 7:33 AM document R6 was, Yelling aggressively to husband (R5) at dining room table and kicked foot at him (R5) when was slow to respond. R6's Progress Notes dated 7/5/22 at 11:30 PM document, (R6) grabbed husband's (R5) arm aggressively trying to get him to follow her. Nurse asked her to not grab him (R5) like that, she (R6) stated, 'Just go on and don't worry about it'. On 8/17/22 at 10:30 AM V2 (Interim Director of Nursing) stated I do believe it is abuse, but they are married. On 8/17/22 at 11:20 AM V1 (Administrator) stated Yes, these instances (6/3/22, 6/28/22, 7/5/22 and 7/29/22) would be physical and verbal abuse. On 8/17/22 at 11:00 AM V1 (Administrator) stated I was not notified of these instances (6/3/22, 6/28/22, 7/5/22, and 7/29/22) and I should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146111 If continuation sheet Page 3 of 6 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 146111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to investigate allegations of physical and verbal abuse for one of three residents (R5) reviewed for abuse in a total sample of 15. Residents Affected - Few Findings Include: The Facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy dated 2/2018 defines verbal abuse as, The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. This policy further documents physical abuse as, Hitting, slapping, pinching, and kicking. This policy also documents, It is the policy of (This Facility) that reports of abuse are promptly and thoroughly investigated. R5 and R6's Medical Record document that the married couple were both admitted on [DATE] both with a diagnosis of Alzheimer's Dementia. R5's Progress Notes (7/29/22 at 11:23 AM) document R5 was noted to have blood running down his arm. These notes document, Wife (R6) said to husband (R5), 'Honey what happened. 'He (R5) replied, 'You scratched me.' Areas measure 0.5 x 0.3 (centimeters), 0.2 x 0.4 (centimeters), and 0.4 (centimeters) x 0.3 (centimeters). R5's Physician Order Sheet dated July 2022 documents Apply TAO (Triple Antibiotic Ointment) to areas daily until healed. R6's Progress Notes document that on 6/3/22 R6 was, being verbally abusive to her husband (R5). R6's Progress Notes dated 6/28/22 at 7:33 AM document R6 was, Yelling aggressively to husband (R5) at dining room table and kicked foot at him (R5) when was slow to respond. R6's Progress Notes dated 7/5/22 at 11:30 PM document, (R6) grabbed husband's (R5) arm aggressively trying to get him to follow her. Nurse asked her to not grab him (R5) like that, she (R6) stated, 'Just go on and don't worry about it'. On 8/17/22 at 10:30 AM V2 (Interim Director of Nursing) stated I do believe it (the 6/3/22, 6/28/22, 7/5/22 and 7/29/22 occurrences) is abuse, but they are married. On 8/17/22 at 11:20 AM V1 (Administrator) stated Yes, these instances (6/3/22, 6/28/22, 7/5/22 and 7/29/22) would be physical and verbal abuse. On 8/17/22 at 11:00 AM V1 (Administrator) confirmed that she had no investigations regarding the documented occurrences between R5 and R6 on 6/3/22, 6/28/22, 7/5/22, and 7/29/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146111 If continuation sheet Page 4 of 6 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 146111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify and remove a fall hazard for one resident (R5) of four residents reviewed for falls in the sample of 15. Findings include: The facility's (undated) Fall Prevention and Follow up policy, documents, Staff will follow the procedures as outlined in this policy in attempts to limit and/or prevent the occurrence of falls. A fall is defined as an unintentional change in position, coming to rest on the ground, floor or onto the next lower surface. This policy also documents, Post Fall Management will include: b. Registered Nurse will investigate fall circumstances and check to see that all prescribed interventions are in place and working properly. On 8/16/22 at 10:35 AM, R5 was sitting in a chair in his room with a walker at R5's bedside. R5 was confused with conversation and was unable to form sentences to communicate. R5's current care plan, dated 6/17/22, documents that R5 was admitted to the facility on [DATE]. This care plan also documents, I have impaired cognitive function/Dementia and impaired decision making. I scored a 4 (severely cognitively impaired) on my BIMS (Brief Interview for Mental Status) assessment and did not show any signs of delirium. Due to my Dementia, I often get up without assistance, I am on behavior tracking. This same care plan also documents, I am at high risk for falling due to having history of falling at home and having falls in past 60 days. R5's electronic medical record documents R5 suffered a fall on 3/2/22, 3/7/22, 5/15/22, 5/16/22, 5/18/22, 5/23,22, 5/30/22, and 6/9/22. All of these documented falls were unwitnessed by staff. R5's record also documents that R6 (R5's spouse) was in the room with R5 or was the person who notified staff of R5 falling for each of the documented occurrence. R5's Progress Notes dated 4/9/22 at 1:00 AM, documents, Resident is alert and sleeps well through the night. Spouse (R6) tries to assist resident with ADLs (Activities of Daily Living). (R5) requires one staff assist with ADLs. (R5) has history of falls. (Fall) alarm in use. (R6) often removes the alarm. R5's Progress Notes dated 4/15/22 at 8:46 AM, documents (R5) alert per his baseline. He is slow to respond and speaks in one-two word answers. Ambulates in hallway, usually holding (R6's) hand. Gait slow and steady. (Fall) alarm is to be in place while (R5) is in recliner or bed as he has a history of falls. (R6) has been noted to be removing alarm at times. R5's Progress Notes dated 5/16/22 at 12:58 AM, documents, Entered (R5's) room when someone was heard yelling, 'Help Me' from inside the resident's room. (R5) was found lying on the floor behind the door in his room. (R5) was assessed by this nurse and was found to have a small skin tear to his right elbow. No other injuries noted. (R5) was then assisted to sit on the bed and Neurological checks were started. Neurological checks WNL (within normal limits) per (R5's) baseline. Resident was then assisted to get ready for bed. Resident's wife (R6) was also found on the floor sitting beside the bed. Both were fully dressed with all their belongings packed to leave. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146111 If continuation sheet Page 5 of 6 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 146111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339 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 0689 Level of Harm - Minimal harm or potential for actual harm R5's Progress Notes dated 5/23/22 at 1:18 PM, documents, Resident's wife (R6) was in their doorway yelling, 'Help, Help'. (R5) observed sitting in front of his closet with his legs extended and his back against the drawers. (R6) said, 'He just kind of slid down'. (R5) was wearing tennis shoes and the floor was dry. He was not wearing his glasses. (R6) had clothes on the bed that she was packing up and a small side table was sitting a few feet in front of the closet. Residents Affected - Few R5's Progress Notes dated 6/9/22 at 4:48 PM, documents, Resident's wife (R6) came to the desk and asked if we could help get (R5) off the floor. (R5) noted to be laying on his left side on the floor in front of the closet. Electric razor cord on the floor by the outlet and razor sitting on table running. (R5) assessed and hematoma noted to left elbow with 1 cm (centimeter) skin tear to bottom edge, no other injury noted. On 8/18/22 at 9:27 AM, V2 (Interim Director of Nursing) stated, We never really gave it a thought that (R6) may be the reason for (R5) falling related to her aggression. Honestly, when we would go into the room after (R5's)falls, there were hazards that (R6) had created. (R6) would turn off nightlights, cover the fall alarm and pack up items and then leaves them on the floor in areas he would trip over. (R6) was a safety hazard for (R5). (R6) was moved out of (R5')s room June 14th, 2022, due to his falls, her aggression and (R6) being possibly the cause of (R5's) falls. (R5) has had no falls since (R6) was moved. On 8/18/22 at 10:12 AM, V1 (Administrator) confirmed that R6 was causing R5 to fall multiple times. V1 stated, During that 6/9/22 fall that was completely (R6), trying to get (R5) to shave or help him shave. Which resulted in the cord being on the floor and (R5) falling. (R5) would not have gotten up and done those things on his own. (R6) was for sure his hazard. (R6) would tell him to get up and get ready and start packing items up in his room. We separated them after more aggressive behaviors were seen (from R6). Since (R6) has been moved, (R5) has not fallen (over two months' time). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146111 If continuation sheet Page 6 of 6