F 0880
Provide and implement an infection prevention and control program.
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 follow their infection control policy and
procedure for 1 of 3 residents (R18) who was on contact isolation precautions for Clostridium difficile
(C-diff).
Residents Affected - Few
Findings include:
R18's Face Sheet, with a print date of 07/17/24, documented R18 has a diagnosis of but not limited to
enterocolitis due to clostridium difficile.
R18's Minimum Data Set (MDS), dated [DATE], documented R18 is cognitively intact with a Brief Interview
for Mental Status (BIMS) of 14 out of 15, and requires assistance with his activities of daily living (ADL).
R18's Progress Notes, dated 7/2/2024 at 5:41 PM, documented R18 was admitted to the local hospital with
pneumonia and C-diff.
On 07/17/24 at 11:02 AM, V21, Certified Occupational Therapy Assistant (COTA) was in R18's room on the
north end of the 100-hall doing therapy with him using exercise bands. V21 was observed not wearing a
gown or gloves. She also was observed to have an over the bed table with her computer, stackable objects,
a blue tote with different items in it, and a gripper on the table.
On 07/17/24 at 11:10 AM V21, COTA came out of R18's room with the table and the bag. She left the table
in the hallway against the wall while she went up to the nurse's station to wash her hands. After she was
done doing hand hygiene, she got the table and pushed it down past the nurse's station to the very end of
the south 100 hallway without any kind of sanitation/cleaning being done to the table or the content on the
table.
On 07/16/24 at 12:39 PM, V6, Licensed Practical Nurse (LPN) stated when someone comes back positive
for C-diff they will put that person on isolation, and staff will use gloves and gowns when going into the
resident's room.
On 07/16/24 at 12:56 PM, V7, Certified Nurse's Assistant (CNA) said when someone is on isolation for
C-diff they are put in a room by themselves and when the staff go into the room, they are to wear a gown
and gloves to be on the safe side.
On 07/17/2024 at 9:30 AM, V2, Director of Nursing (DON) stated R18 is the only resident in the facility at
this time who has C-diff. She said he just finished up his antibiotic and his stools are
(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 2
Event ID:
145410
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
145410
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare of Breese
1155 North First Street
Breese, IL 62230
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
starting to be more formed. V2 said when someone is confirmed to have C-diff they will immediately move
the resident to another room especially if they both don't have C-diff and she would expect treatment to be
started immediately. V2 said she would expect staff to be wearing a gown and gloves when going into a
room with someone who has C-diff.
On 07/17/24 at 12:46 PM, V2, Director of Nursing stated she would absolutely expect for staff to wear the
proper personal protective equipment (PPE) when caring for a resident who is on isolation for C-diff.
On 07/18/24 at 2:35 PM, V11, Infection Control Preventionist (ICP) stated if someone was positive for C-diff
they would be placed on contact isolation. She would expect any staff who went into the room to give any
kind of care to wear a gown and gloves and that includes occupational therapy, she would expect them to
do proper hand washing after they were done with the resident's care. She stated staff should not be
bringing anything into a room of a resident who has C-diff. If it's bed linens or something like that, they
should be disposing of the dirty ones in the dirty linen bin in the resident's room. If they are bringing in any
kind of therapy equipment, they should be wiping it down with the appropriate disinfectant wipe before
bringing it out of the room.
The facility's policy Infection Control Practices Clostridium Difficile, revised date of 03/2004, documented
Purpose: The purposes of this procedure are to provide guidelines for the care of persons with Clostridium
Difficile, verified by culture or by evidence of positive cytotoxin assay, and to prevent transmission of
Clostridium Difficile to others. It further documented Infection Control Protocol and Safety 4. Wear
appropriate personal protective equipment (e.g. gloves, gown, mask, eyewear, etc. as necessary) to prevent
exposure to spills, splashes of blood or other potentially infectious materials. 5. Maintain clean technique
and isolation precautions as indicated. 6. After completion of the procedure, clean, store and/or dispose of
equipment and supplies in the appropriate manner as identified per facility infection control policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145410
If continuation sheet
Page 2 of 2
