Inspection·December 10, 2024

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 place a soiled incontinence brief in a trash receptacle and failed to remove soiled gloves before touching clean items in a resident room for one of three residents (R2) reviewed for infection control in the sample of six. Residents Affected - Few Findings include: The facility's Infection Prevention and Control Program policy, revised 11/28/17, documents, Purpose: To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for All residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Guidelines: 1. The facility has established an Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risk of nosocomial infections in residents and health care workers. On 12/10/24 at 11:00am V3 (RN/Registered Nurse) was preparing to do wound care on R2. Upon unfastening R2's incontinence brief, it was noted that R2 had a bowel movement. While wearing clean gloves, V3 removed R2's stool covered wound dressing, placed it in the soiled incontinence brief, rolled the brief, removing it from R2, and placed it on the floor by V3's feet. While wearing the same soiled gloves, V3 grabbed the door handle to R2's room and looked out into the hallway for V10 (Certified Nursing Assistant/CNA). V10 entered R2's room with clean towels and wash rags. V3 (RN) took the clean linens from V10 with V3's soiled gloved hands. V3 (RN) went to the side of R2's bed, moved the soiled incontinence brief, that was on the floor, with V3's shoe and proceeded to provide incontinence care to R2 while wearing the same soiled gloves. On 12/10/24 at 11:30am V3 (RN) stated she usually places dirty incontinence briefs in a trash can if available but if not places on the floor, then picks them up when she is done with cares. V3 (RN) also stated she was not aware she should not touch clean items with soiled gloves on. 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: 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 12/10/2024 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)