Goldwater Care Clinton

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to protect the resident's right (Resident R3) to be free of physical abuse from (Resident R2) for two of six residents reviewed for abuse in the sample list of 19.Findings include:Resident R2's Abuse/Neglect Screening form dated 5/1/25, documents Resident R2 has a history of mistreating others by physical and verbal abuse, psychiatric mental health issues which include psychotic symptoms, and documents Resident R2 cries a lot and them becomes angry with other residents.Resident R2's undated diagnoses list documents the following diagnoses: other specified Anxiety Disorder, and Alzheimer's Disease, unspecified. Resident R2's Progress Note/Psychotropic dated 8/21/25, documents Resident R2's diagnoses as: Major Depressive Disorder, Dementia in other diseases classified elsewhere, severe, with Agitation, and Anxiety with somatic features.Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED], documents Resident R2 is not cognitively intact.Resident R2's Care Plan dated 8/27/25, documents Resident R2 has a problematic manner characterized by ineffective coping, verbal/physical aggression related to cognitive impairment.The facility's abuse report dated 8/21/25, documents Resident R3 was in Resident R2's room where Resident R3 was lying in Resident R2's bed. Resident R2 made physical contact with Resident R3's upper thigh.On 9/10/25 at 2:03 PM, V3 Certified Nursing Assistant (CNA) stated Resident R2 is very verbal, tries to reach for other residents, takes their arms and grabs them often. V3 stated staff has to call Resident R2's daughter V13, to have V13 sit with Resident R2 to calm Resident R2 down. On 9/16/25 at 12:22 PM, V1 Administrator stated Resident R2 is a resident who has been physical with residents.On 9/17/25 at 10:35 AM, V2 Director of Nursing (DON) stated Resident R2 did hit Resident R3 on 9/11/25.The facility's Abuse Prevention and Reporting Policy dated Revisions 10/24/22, documents the facility affirms the right of the residents to be free from abuse and therefore prohibits abuse.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to provide multiple scheduled showers for dependent residents. This failure affected three of three residents (Resident R6, Resident R8, Resident R9) reviewed for showers on the sample list of 19. Findings Include: Facilities Bathing - Shower and Tub Bath Policy dated January 2018 documents: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, two times per week or according to the resident's preferred frequency and as needed or requested. Staff are to document bathing task and assistance provided in the electronic record, including pertinent observations. 1. Resident R6's Medical Diagnoses list dated September 2025 documents Resident R6 is diagnosed with Unspecified Dementia, Generalized Anxiety, Parkinson's Disease, Insomnia, Pressure Ulcer of the Sacral Region, Overactive Bladder, Congestive Heart Failure, and Abnormalities of the Gait and Mobility. Resident R6's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R6 is Dependent on staff assistance for Shower/Bathing. Resident R6's Shower/Bathe Task for the last 30 days documents Resident R6 is scheduled to receive showers on Tuesday and Fridays from 6:00 PM - 6:00 AM. This same record documents Resident R6 received a shower on 8/20/25, 8/23/25, 9/3/25, 9/6/25 and 9/17/25, there are no other documented showers, baths or refusals in Resident R6's electronic medical record. 2. Resident R8's Medical Diagnoses list dated September 2025 documents Resident R8 is diagnosed with Chronic Kidney Disease Stage 3, Muscle Wasting and Atrophy, Sepsis, Gangrene and Diabetes Type II. Resident R8's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R8 requires partial/moderate assistance for Shower/Bathing. The facility's Shower List dated 8/1/25 documents Resident R8 is supposed to have showers on Tuesday and Friday from 6:00 PM - 6:00 AM. Resident R8's Shower/Bathe Task for the last 30 days documents Resident R8 received a shower on 8/26/25, 9/2/25 and 9/12/25 and refused showers on 9/3/25 and 9/5/25. There are no other documented showers, baths or refusals in Resident R8's electronic medical record. 3. Resident R9's Medical Diagnoses list dated September 2025 documents Resident R9 is diagnosed with Dementia, Delusional Disorder, Depression, Need for Assistance with Personal Care. Resident R9's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R9 requires partial/moderate assistance for Shower/Bathing. The facility's Shower List dated 8/1/25 documents Resident R9 is supposed to have showers on Tuesday and Friday from 6:00 AM - 6:00 PM. Resident R9's Shower/Bathe Task for the last 30 days documents Resident R9 received a shower on 8/26/25 and 9/9/25 and refused showers on 8/22/25 and 9/12/25.

There are no other documented showers, baths or refusals in Resident R9's electronic medical record. On 9/18/25 at 2:30 PM V1 Administrator confirmed the facility provides two showers per week to residents and staff should document when showers are given or refused. On 9/18/25 at 2:45 PM V2 Director of Nurses confirmed the facility provides two showers per week for residents and staff should document the showers

in the resident's electronic medical record under Task section under the bathing task. V2 confirmed staff should be documenting if a shower is given or refused and if refused staff should be notifying the nurse who should reapproach the resident and address any barriers.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to complete multiple wound dressing treatments and failed to address a residents repeated refusals for wound treatment. This failure affected one of three residents (Resident R9) reviewed for wounds on the sample list of 19. Findings Include: The facility's Pressure Injury and Skin Condition assessment dated [DATE REDACTED] documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and assuring interventions are implemented. Dressing should be changed in accordance with physician orders and documented in the Treatment Administration Record (TAR). Physician ordered treatments shall be initialed by the staff on the electronic TAR after each administration. Resident R9's Medical Diagnoses list dated September 2025 documents Resident R9 is diagnosed with Dementia, Delusional Disorder, Depression, Need for Assistance with Personal Care, and Malignant Neoplasm of unspecified Site of Right Female Breast. Resident R9's Physician Order Sheet dated September 2025 documents an order for a wound treatment to her Right Breast to be completed daily.Resident R9's Care Plan dated 4/14/25 documents Resident R9 has a cancer ulcer under her right breast and staff are to perform treatments per physician order. Resident R9's September 2025 Treatment Administration Record (TAR) documents three wound treatments not completed and eight refused wound treatments between 9/1/25 and 9/17/25. Resident R9's August 2025 Treatment Administration Record (TAR) documents five wound treatments not completed and three refused wound treatments.Resident R9's July 2025 Treatment Administration Record (TAR) documents one wound treatment not completed and four refused wound treatments. On 9/18/25 at 2:45 PM, V2 Director of Nurses confirmed staff should be completing wound orders according to physician order. If they are not completed or if the resident has repeated refusals, the staff should notify the physician and document in the resident's electronic medical record.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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 0689

in-service on 8/22/25 for all nurses; and Incident Correction and IDT Completion Plan in-service on 8/22/25, for all nurses.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 104 residents in the facility. Findings Include: Facility Nursing Hall Assignment Sheets reviewed from 8/27/25 through 9/15/25 documented nine days (8/27, 8/28, 9/2, 9/3, 9/4, 9/9, 9/11, 9/13, 9/14) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 9/18/25 at 2:30 PM V1 Administrator confirmed there were days with no RN staffing available. V1 also confirmed the facility's average daily census was around its current census of 104 residents. The Bed Management sheet dated 9/10/25 documents a current census of 104 residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on interview and record review, the facility failed to ensure resident records were accurately documented and maintained for five residents (Resident R12, Resident R13, Resident R14, Resident R15, Resident R16) of five residents reviewed for documentation in the sample list of 19.Findings include:The facility's Employee Disciplinary Form dated 7/22/25, documents V12 Certified Nursing Assistant (CNA), received a final warning regarding incomplete documentation. This report documents five residents (Resident R12, Resident R13, Resident R14, Resident R15, Resident R16) were audited with 10 Activities of Daily Living (ADL) examples, totaling 40 occurrences of mis-documentation occurring in the past 30 days. This form documents Resident R12 having 6 occurrences, Resident R13 having 16 occurrences, Resident R14 having 6 occurrences, Resident R15 having 10 occurrences, and Resident R16 having two occurrences of mis-documentation. On 9/17/25 at 10:13 AM, V1 Administrator, stated V12 CNA had been terminated on 9/15/25, due to false charting previously for documenting giving baths but did not do the baths.

Event ID:

Facility ID:

If continuation sheet