Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based upon observation, interview and record review, the facility failed to provide clean, stain-free linens for
bathing for 9 residents (R7, R15, R22, R25, R30, R32, R44, R48 and R57) of 9 residents reviewed for
dignity, in a sample of 30.
The facility policy, Dignity, dated (reviewed) 4/23/18 directs staff, The facility shall promote care for residents
in a manner and in an environment that maintains or enhances each resident's dignity and respect in full
recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to
maintain and enhance his/her self-esteem and self-worth.
1. On 4/29/24 at 10:38 A.M., R44 held up two (2) discolored wash clothes which had brown/tan stains. R44
stated Would you want to wash yourself with these? This is gross. This is supposed to be my house and I
sure wouldn't use this to wash my car. It's not dignified. I even posted pictures on (Social Media). Ever since
this new company took this place over, they can't get wipes, so they (staff) have to wipe our a***s with
them. Then they just put them right back in the laundry. I bet those washing machines are full of feces and
that's not right. Go culture them and see what grows out of them. I feel so contaminated
2. On 4/29/24 at 9:46 A.M., R25 was seated in her wheelchair, in her room. At that time, R25 stated, I'm so
upset about this. Look at this filthy washcloth. Staff brought this into my room this past weekend and wanted
me to use it to wash my face. It's a dignity problem. It is so undignified to even think of using something that
someone else used to wipe their butt with. They took away our disposable wipes and told us we have to use
these stained up washcloths. Last week when I went to take my shower, they wanted me to sit on a
community shower chair that was covered with a blood stained white towel. R25 held up a greyish-looking
washcloth covered with brown stains.
On 4/29/24 at 10:55 AM, V7 (Housekeeping Manager) stated If the laundry is stained after we wash it, we
pull it out and give it to housekeeping or the kitchen to use as rags. Over there (pointed at multiple boxes on
clean side of laundry room) are full of brand new towels and wash clothes. If it is really bad (dirty
washcloth), the CNA's are suppose to wash it in the hopper and put it in a bag before they put it in the
laundry. It gets cleaned with all other whites. Soiled (wash clothes saturated with brown substances.)
laundry was observed in the laundry bin in front of the washing machine. V7/Housekeeping Manager
verified the laundry in the bin with the soiled material was ready for wash.
3. On 4/29/24 at 2:47 P.M., V48 stated, I am the (facility) Resident Council President. Many residents have
voiced concerns to me about dingy, brown stained washcloths that we are given for bathing. We feel
demeaned by being forced to use (feces) stained washcloths to wash ourselves.
(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 9
Event ID:
145413
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 4/30/24 at 1:00 P.M., during the facility Group Meeting, R48 stated, Please do something about these
dirty, stained wash cloths they make us wash with. It is demeaning to be treated this way. At that time, the
other residents in attendance (R7, R15, R22, R30, R32 and R57) were in agreement.
On 4/30/24 at 2:40 P.M., V1/Administrator stated, Our company policy is that we no longer buy (disposable)
wipes for incontinence care. Staff have to use washcloths for peri care. They're not supposed to use the
stained ones. I will talk to laundry and remind them to throw the stained ones away.
Event ID:
Facility ID:
145413
If continuation sheet
Page 2 of 9
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and
Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of two
residents (R2) reviewed for PASARR screening, in the sample of 30.
Findings include:
The facility policy, Preadmission Screening and Annual Resident Review (PASARR), reviewed 11-13-18
documents, It is the policy to screen all potential admissions on a individualized basis. As part of the
preadmission process, the facility participates in the Preadmission Screening and Resident Review
screening process (Level 1) for all new and readmissions per requirement to determine if the individual
meets the criteria for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Annually
and with any significant change of status, the facility will complete the PASARR Level 1 screen for those
individuals identified per the Level 11 screen requiring specialized services.
R2's current Physician Order Sheet, dated May 2024 documents that R2 was admitted to the facility on
[DATE] with the following diagnoses: Bipolar Disorder and Major Depressive Disorder.
R2's current PASAAR screen, provided by V2/Director of Nurses on 4/29/24, documents R2 was originally
admitted to a Skilled Nursing Facility on 3/26.97 with no diagnosis of Severe Mental Illness.
On 4/29/24 at 12:27 P.M., V2/Director of Nurses verified that R2 has not had a PASAAR rescreen upon
admission to the facility, despite R2's diagnoses of severe mental illness.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 3 of 9
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on interview, observation and record review, the facility failed to ensure a resident was safely during
transport in the facility's transport van for one of two residents (R7) reviewed for falls in the sample of 30.
Residents Affected - Few
Findings include:
R7's medical record documents R7's diagnoses to include: Dependence on wheelchair; Diabetes Mellitus
doe to underlying condition with Diabetic Autonomic Neuropathy; and Acquired Absence of Left Leg.
R7's Fall Investigation (dated 02/14/24) documents R7 fell in the facility's transport van while in route to a
doctor's appointment.
R7's current Fall Risk Care Plan documents the following fall prevention intervention implemented on
02/14/24: Educate bus driver and resident on seatbelt safety while in wheelchair.
On 04/30/24 at 01:30 PM during the group meeting, R7 stated he fell in the facility's transport van while he
was being transported to a doctor's appointment. R7 stated he had pain in his right leg and was transported
to a local hospital emergency room for evaluation, and then returned to the facility later that same day once
he was discharged from the emergency room.
On 05/02/24 at 09:35 AM, R7 was sitting in his electric wheelchair in his room going through items in
drawer of a storage bin. R7 was dressed and groomed, and a full mechanical lift was in place underneath of
him. R7 stated he can recall the fall he had in the facility van on 02/14/24. R7 stated he was not sitting in
the usual spot he sits in the transport van due to another resident present in the van being transported to
an appointment. R7 lifted up his shirt exposing his wheelchair seat belt, which was fastened. R7 stated he
was not wearing his wheelchair seatbelt at the time of his 02/14/24 fall, and the transport van's lap belt that
goes across his lap during transport was loose enough to allow him to slip forward out of his wheelchair
when the van came to a stop.
On 05/02/24 at 08:50 AM, V14 (Van Driver) entered the facility's transport van parked in front of the facility
and stated the following: I had just started this job when (R7) fell in the van. I believe it was my second
week. I had two residents in the van that day. They were both going to doctor's appointments. We
approached a stop sign, and (R7) fell out of his wheelchair. I did not know it at the time, but he has a
seatbelt on his electric wheelchair and it was not fastened. His wheelchair was secured in place, but the
seatbelt in the van was not tight enough. (R7) had me loosen it before we took off that day because he said
it was uncomfortable. It should have been much tighter. I know better than to allow this now. V14 then
pointed to the seatbelt in the van and demonstrated how to tighten it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 4 of 9
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on interview, observation and record review, the facility failed to attempt a gradual dose reduction
twice in two separate quarters within the first year prescribed and document a consistent pattern of adverse
behaviors for one of three residents (R38) reviewed for one of four residents (R38) reviewed for
psychotropic medications in the sample of 30.
Findings include:
The facility's Psychotropic Medication - Gradual Dose reduction policy (revised 02/01/18) documents the
following: Residents who use psychotropic drugs shall receive gradual dose reductions and behavior
interventions, unless clinically contraindicated, in an effort to discontinue or reduce the medication. A
gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction
have been unsuccessful or reduction is clinically contraindicated. The drug reaction will continue until
eliminated or the clinical condition of resident worsens.
R38's medical record documents R38's diagnoses to include: Major Depressive Disorder, Recurrent severe
without psychotic features; Alcoholic Polyneuropathy, Insomnia, Deficiency of specified B group vitamins;
Generalized Anxiety Disorder; Alcohol Dependence with Alcohol-induced persisting Amnestic Disorder;
Amnesia; and Dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood
disturbance and anxiety.
R38's current Physician's Orders document the following medication order: Seroquel (antipsychotic) give 50
milligrams by mouth two times a day (initial date of order 05/18/23).
On 04/29/24 at 01:20 PM, R38 was sitting up in bed with the head of the bed elevated approximately 60
degrees operating his laptop. R38 was dressed and groomed, and a call light and oral fluids were within his
reach. Several personal items were present in R38's room, including a large keyboard. R38 stated, I used to
be a music teacher and caused some issues in my brain when I used to drink alcohol. I now am writing
songs on my tablet since I am here and cannot teach anymore. R38 stated all is going well at the facility
and he is currently in the process of applying for disability, Once I get disability I want to discharge and get
my own place. R38 did not display any adverse behaviors during this time.
R38's Monthly Behavior Monitoring Sheets (dated 11/2023 - 4/2024) document R38 is being monitored for
the following target behaviors: Agitation/Anxiety/Restlessness; Verbally Aggressive. These forms document
R38 displayed 5 or less episodes of these behaviors each month, except R38 displayed 7 episodes of
Agitation/Anxiety/Restlessness in March 2024.
On 05/01/24 at 01:20 PM, V2 (Director of Nursing) stated the following when asked what behaviors R38
displays: Loud noises will trigger and agitate (R38). V2 stated R38 is not a harm to himself of others, and
the behaviors that R38 displays do not warrant the use of an antipsychotic medication. V2 confirmed R38
has been on the same dose of the antipsychotic, Seroquel, since it was initially ordered a year ago, and a
gradual dose reduction has not been attempted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 5 of 9
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to conduct the required quarterly Quality Assurance
meetings and failed to ensure the required Quality Assurance committee members were in attendance.
These failures have the potential to affect all 63 residents currently residing in the facility.
Residents Affected - Many
FINDINGS INCLUDE:
The facility policy, Quality Assurance and Performance Improvement Plan, dated (effective) January 02,
2024 documents, The QAPI program at (the facility) will aim for safety and high quality with all clinical
interventions and service delivery while emphasizing autonomy, choice and quality of daily life for residents
and family by ensuring our data collection tools and monitoring systems are in place and are consistent for
proactive analysis, system failure analysis and corrective action. The Quality Assessment and Assurance
Committee reports to the executive leadership and Governing Body and is responsible for meeting for:
Meeting, at a minimum, on a quarterly basis; more frequently, if necessary. The Quality Assessment and
Assurance Committee will consist of the Medical Director/Designee, Director of Nursing Services,
Administrator/Owner/Board Member/Other Leader, Infection Prevention and Control Officer, Maintenance,
Business Officer Manager, Minimum Data Set Nurse, Wound Nurse, Social Services Director, Activity
Director, Dietary Manager and Housekeeping Supervisor.
The facility Quality Assurance Performance Improvement Meeting Minutes attendance sign-in sheets,
provided by V1/Administrator include April 12, 2023 (missing Medical Director signature); February 8, 2024
and April 3, 2024 (missing Medical Director and Director of Nurses signature). No Quality Assurance
Performance Improvement Meeting Minutes are available for July and October 2023 or January 2024.
On 05/02/24 at 9:09 A.M., V1/Administrator verified the missing signatures for the 4/12/23 and 4/3/24
sheets. At that time, V1 also confirmed the missing sign in sheets for July 2023, October 2023 and January
2024.
The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated
4/30/2024 and signed by V1/Administrator documents 63 residents currently reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 6 of 9
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to utilize PPE (Personal Protective
Equipment), failed to audit for appropriateness/compliance of PPE and failed to screen staff during a
COVID-19 outbreak. This has the potential to affect 63 residents residing in the facility.
Residents Affected - Many
Findings include:
The Infection Control-Interim COVID-19 policy, dated 7/24/23, PPE Use in Red & Yellow Zone Residents
with Suspected or Confirmed COVID-19 Infection HCP (Health Care Providers) who enter the room of a
resident with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and
use a NIOSH (National Institute of Occupational Health) approved particulate respirator with N95 filters or
higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the
face). Respirators should be used in context of a comprehensive respiratory protection program, which
includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health
Administration's (OSHA) Respiratory Protection standard. PPE including N95 should be discarded and new
applied between each resident encounter, Testing of Staff and Residents: Newly identified COVID-19
positive staff or resident in a facility that can identify close contact. Test all staff regardless of vaccination
status that had a higher-risk exposure with a COVID-19 positive individual. Test all residents, regardless of
vaccination status that had close contact with a COVID-19 positive individual.
The Infection Surveillance, Tracking and QA (Quality Assurance) Reporting policy, dated 2/14/18, Purpose:
To identify, monitor, track and report infections and monitor adherence to infection control practices.
Infection surveillance for compliance may include but is not limited to: Direct observation of care and
procedures performed by staff. Direct observations of adherence to hand hygiene and proper use of PPE.
Monitoring the availability of PPE.
The Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for
Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 3/18/24,
Personal Protective Equipment HCP (Health Care Providers) who enter the room of a patient with
suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH.
Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or
a face shield that covers the front and sides of the face).
The CDC's NIOSH-Approved Particulate Filtering Facepiece Respirators this list is reviewed and updated
weekly, A respirator labeled as a KN95 respirator is expected to conform to China's GB2626 standard.
NIOSH does not approve KN95 products or any other respiratory protective devices certified to
international standards.
R317's Physician's Orders, dated 4/29/24, Follow Facility Protocol for COVID19 Screening/Precautions
Droplet Precautions.
On 4/29/24 at 10:06 AM, outside of R317's room posted on wall next to the door was a Droplet and
Contact/Red Zone precautions signage.
On 4/29/24 at 10:07 AM, V6 (Agency Certified Nursing Assistant) donned PPE and entered R317's room
without tying the gown closed. V6 stated I'm Agency. This is my first rodeo here. They asked me to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 7 of 9
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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
come in 15 minutes early to get the door codes and had a basic quick introduction and then I got started.
Level of Harm - Minimal harm
or potential for actual harm
On 4/29/24 at 10:10 AM, R317 was observed to leave the room with a mask on and no other PPE. R317
walked down to nurse's station and was then redirected back to R317's room by V4 (Registered Nurse).
Residents Affected - Many
On 4/29/24 at 10:11 AM, V4 (Registered Nurse) was observed to enter R317's room without donning PPE
(N-95, goggles, gloves and/or gown). V4, sat R317 down in a chair, took disposable stethoscope and blood
pressure cuff out of R317's hands and put it on the overhead table. V4 exited the R317's room and
performed hand hygiene.
On 4/29/24 at 10:13 AM, V4 stated, R317 wanders out in the hall all day and has to be redirect back to
R317's room.
On 4/30/24 at 11:55 AM, R317 was walking down B-hall with a mask donned and V10 (Registered Nurse)
redirected and escorted R317 back to R317's room. R317 was observed to immediately walk out of room,
past V10 and walked to the nurse's station approximately 45 ft. V9 (Registered Nurse) was observed at the
Nurses Station and redirected and escorted R317 back to R317's room. At 11:58 AM, R317 walked back
out into the B-hall, again walked past V10 to nurse's station where the V9 stated I Know you are hungry.
Lunch is coming soon and escorted R317 back to her room.
The Infection Prevention COVID positive tracking list, dated 3/1/24 through 5/1/24, documents R317 tested
positive for COVID-19 on 4/23/24, R60 tested positive for COVID-19 on 4/23/24 and R63 tested positive for
COVID-19 on 4/29/24.
On 4/30/24 at 10:00 AM, a Droplet and Contact/Red Zone precautions sign was post outside of R63's and
R60's room (directly across from one another) in B-hall.
On 5/1/24 at 1:00 PM, two PPE supply cabinets in the B-hall outside of R63's room and outside of R317's
room each contained 1 (one) box each with 20 (twenty) KN95 Disposable Non-Medical Face Masks
Product Model: JDK-01, Jinhue Jiadaifu Medical Supplies Company.
The CDC guidelines do not list KN95 Disposable Non-Medical Face Masks Product Model: JDK-01, Jinhue
Jiadaifu Medical Supplies Company as NIOSH approved mask.
On 5/1/24 at 2:08 PM, V13 (Agency CNA) stated If I have to go into one of those rooms (R63 and/or R60's
COVID isolation rooms), I use the PPE out of that cabinet (V15 pointed at the cabinet outside of R63's
room which contained the non-approved NIOSH KN95 masks.) V15 (CNA) was present and stated V15
would as well use the PPE in the cabinet.
On 5/1/24 at 2:10 PM, V16 (Occupational Therapy Assistant) was observed in R63's room with the
non-approved NIOSH mask donned.
On 5/1/24 at 12:49 PM, V3 (Infection Control Preventionist) stated I'm going to start doing PPE audits since
we have had this big outbreak. I only monitor hand hygiene compliance now.
The Daily Shift Assignment form dated 4/20/24 through 4/30/24 documents the following: 10 Agency staff
worked on 4/23/24; 5 agency staff on 4/26/24; 4/29/24 7 agency staff.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 8 of 9
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
145413
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Toluca
101 East via Ghiglieri
Toluca, IL 61369
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
On 5/1/24, the Staff Source Testing binder included facility staff rapid COVID-19 testing results conducted
on 4/23/24, 4/26/24 and 4/29/24. The binder lacked documentation that Agency staff were tested.
On 5/1/24 at 12:35 PM, V17 (Agency Certified Nurse Aide/CNA) stated Our Agency doesn't have us test
(COVID-19). No, they didn't test me here.
Residents Affected - Many
On 5/1/24 at 12:45 PM, V13 (Agency CNA) stated Our Agency does not require testing (COVID-19). I just
got done doing the on-boarding paperwork with the DON (Director of Nursing) and nothing was said about
testing. They (facility) haven't tested me.
On 5/2/24 at 1:00 PM, V3 stated Agency staff are not included in source testing for COVID-19. V3 agreed
without including the Agency staff in the source testing, the sampling would be skewed and not all-inclusive.
2. 4/29/24 at 12:30pm, V4, Registered Nurse, entered R60's room to pass medications. R60's has a RED
ZONE sign on the door, indicating that R60 is on droplet precautions and full personal protective equipment
is required. V4 had on a surgical mask, then donned a plastic face shield. V4 entered R60's and gave her
the medication. V4 exited R60's room and used hand sanitizer and removed the plastic face shield. V4
continued to pass the medication on the unit. V4 verified that she did not don full PPE prior to entering
R60's droplet isolation room. V4 also stated that she did not change her change her mask after leaving
R60's room.
The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 4/30/24,
documents that 63 residents reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 9 of 9
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the May 2, 2024 survey of GOLDWATER CARE TOLUCA?
This was a inspection survey of GOLDWATER CARE TOLUCA on May 2, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GOLDWATER CARE TOLUCA on May 2, 2024?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.