Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Goldwater Care Toluca during CMS and state inspections, most recent first.
A resident with multiple medical and psychosocial conditions, including anxiety, depression, hepatic encephalopathy, chronic pain, and impaired vision, was care planned as being at risk for abuse/neglect. After the resident became upset when a CNA could not obtain a requested salad, the CNA reported the interaction to the Social Service Director, who then entered the resident’s room. According to the resident and multiple staff, including a COTA and DON, the Social Service Director approached the resident with an angry attitude, got close to the resident’s face, and used profane and degrading language, calling the resident an "a******" and using additional obscenities while defending the CNA. The resident reported feeling humiliated and degraded. Other staff and a resident council leader reported prior concerns and complaints about this staff member’s behavior. These events occurred despite facility policies that prohibit abuse, define mental and verbal abuse, and require staff to treat residents with courtesy and respect at all times.
The facility failed to employ a certified Food Service Manager/Dietary Manager despite its own assessment and job description identifying this position as necessary to oversee food and nutrition services for 63 residents. For about two months, there was no designated dietary manager, with the DON intermittently overseeing the department and dietary staff informally sharing management tasks. Resident council records and interviews with residents, dietary staff, a contracted RD, an ombudsman, and a contracted dietary supplier all confirmed the absence of a manager and described significant problems with food service, including meals not matching posted menus, cold or undercooked food, lack of menu choices, frequent shortages of coffee and milk, inedible salads, and inadequate snacks for a resident with diabetes and a resident on a special diet.
The facility failed to follow its planned, dietician-reviewed menus and did not consistently provide the listed food items or nutritionally balanced meals. The facility assessment and policies required a Dietary Manager and adherence to planned menus, but the position had been vacant for months, with the DON informally overseeing the kitchen and dietary staff improvising due to supply issues and budget-driven order cuts. On multiple occasions, planned menu items such as ham in a western egg bake and baked potatoes were not served, and substitutes like sweet potatoes were used instead. Several alert and oriented residents reported that food was often cold, undercooked, not edible, lacking in variety or choice, and did not match the menu or their special diets, with frequent shortages of milk, coffee, salads, and appropriate snacks for conditions such as diabetes. Staff and a contracted supplier confirmed recurring shortages, poor portion control, and mismanagement of ingredients, leading to routine deviations from the posted menus.
A resident became upset when a CNA could not obtain a requested salad, leading to a conflict that prompted the Social Service Director to enter the room. According to multiple staff statements and the resident’s own account, the Social Service Director approached the resident aggressively, got close to the resident’s face, and used profane, degrading language, including calling the resident an “a******” and telling the resident not to be a “f****** a******” to staff. A COTA overheard the interaction while providing therapy to the roommate and immediately reported it to the DON. Although the facility’s abuse policy defines such conduct as mental and verbal abuse and requires prompt identification and reporting, the final investigation concluded that no verbal abuse occurred and treated the behavior only as unprofessional language, resulting in a failure to properly identify and substantiate abuse.
QA/QAPI meetings were not documented with the required Medical Director attendance, and one month’s minutes could not be produced. The facility’s policy required quarterly committee meetings and retention of minutes and attendance records, but the available minutes did not show the Medical Director present at multiple meetings. The Administrator stated monthly QA meetings were held and that the Medical Director was only updated when available because scheduling was difficult.
Failure to monitor the facility water system for Legionella. The facility's water management program required weekly verification of hot water temperatures and mixing valve settings, but the Maintenance employee stated the facility uses a hot water heater rather than a boiler and does not keep a weekly log of hot water heater temperatures. The roster showed 61 residents in the facility.
A resident admitted with severe vascular dementia with agitation was ordered Quetiapine 150 mg at bedtime for that diagnosis, and the MAR showed it was administered as ordered for the past 3 months. The record also included psych provider notes supporting the order, but the DON verified that the diagnosis did not justify use of the antipsychotic.
Failure to Notify Representatives and Ombudsman of Resident Transfers/Discharges: The Facility did not document notification of Resident Representatives or the reason for discharge for two residents transferred out after falls and ED evaluations. One resident's Bed Hold Policy Notice did not show that a copy was mailed to the Representative, and the Ombudsman discharge/transfer logs did not include that resident's discharge. The records also lacked the required discharge notification details.
A resident with COPD, respiratory failure, chronic pain, neuropathy, vascular dementia, seizures, contractures, dysphagia, bipolar disorder, and depression returned from a hospitalization with Hospice services and was later discharged from Hospice. The care plan still listed Hospice-related interventions, including notifying Hospice of condition changes and providing discharge and bereavement care, and the DON confirmed the plan should have been updated.
A resident with multiple serious diagnoses was transferred to the hospital, but the chart lacked a nursing assessment, transfer time, details of the condition change, and documentation of physician or representative notification. In a separate issue, an LPN signed off on ordered wound care for another resident’s chronic groin wound before the treatment was actually done, while the resident reported the twice-daily treatments were often missed and the DON confirmed staff should document only after care is provided.
A resident with CHF and other chronic conditions did not have ordered daily weights completed, and the DON confirmed the physician was not notified of significant weight gains or discrepancies. Another resident with dysphagia, dementia, and no teeth had conflicting diet orders after hospital and hospice care, and staff did not clarify the diet before feeding; the resident complained about being given an unwanted mechanical soft diet and not receiving preferred foods.
A resident receiving daily nebulizer treatments had a nebulizer mask and tubing that were not labeled with a date showing when they were changed, despite a physician order to change, date, and label the equipment weekly and as needed. The facility policy also required the handheld nebulizer to be changed weekly and as needed, and an LPN confirmed oxygen equipment should be dated.
Failure to Track and Justify Prophylactic Antibiotic Use: A resident with cerebral palsy, DM2, morbid obesity, schizophrenia, follicular disorder, and idiopathic progressive neuropathy had an open-ended prophylactic doxycycline order. The facility’s infection logs did not document the ongoing antibiotic use, and no physician rationale was provided for the long-term prophylactic order, despite the facility’s antibiotic stewardship policy requiring logging, tracking, and justification.
A resident with a history of wrist fracture fell and injured her left wrist when a CNA failed to use a gait belt during a transfer, contrary to facility policy. The CNA attempted to assist the resident off the toilet by grabbing her bra, causing the resident to lose balance and fall. The resident was hospitalized with an acute wrist fracture and prescribed a wrist splint and pain medication.
The facility failed to employ a certified Infection Prevention Nurse, affecting all 62 residents. An Infection Prevention Nurse was hired but is not yet certified, although she is signed up for courses. Her employee file confirmed her hire date but lacked certification or training documentation.
A registered nurse failed to follow proper infection control protocols during wound care for a resident. The nurse used the same soiled gloves to handle clean items and placed a soiled incontinence brief on the floor, compromising infection prevention measures.
The facility failed to conduct the required quarterly QA meetings and did not ensure the attendance of required committee members. Missing signatures from key members and the absence of meeting minutes for several months were confirmed by the Administrator. These failures have the potential to affect all 63 residents currently residing in the facility.
The facility failed to utilize appropriate PPE, audit for PPE compliance, and screen staff during a COVID-19 outbreak, potentially affecting 63 residents. Staff did not consistently adhere to PPE guidelines, and non-approved KN95 masks were used. Agency staff were not included in COVID-19 source testing, and specific incidents showed lapses in infection control practices.
The facility failed to provide clean, stain-free linens for bathing, compromising the dignity of nine residents. Observations and interviews revealed that residents were given discolored washcloths with brown/tan stains for personal hygiene. The Housekeeping Manager confirmed that stained linens were supposed to be repurposed, but soiled washcloths were observed in the laundry bin ready for washing with other whites. The Administrator acknowledged the policy change to no longer provide disposable wipes, requiring staff to use washcloths instead.
The facility failed to perform a PASARR rescreen for a resident diagnosed with Bipolar Disorder and Major Depressive Disorder upon admission, despite the facility's policy requiring rescreening with any significant change of status. The DON confirmed the oversight.
A resident with multiple diagnoses fell in the facility's transport van due to an improperly secured seatbelt. The van driver, new to the job, had loosened the seatbelt at the resident's request, leading to the fall. The resident required hospital evaluation for pain in his right leg.
The facility failed to attempt a gradual dose reduction for a resident prescribed Seroquel for a year, despite minimal documented episodes of agitation and anxiety. The DON confirmed that the resident's behaviors did not warrant the continued use of the antipsychotic medication, and a GDR had not been attempted as required by the facility's policy.
Failure to Protect a Resident From Verbal and Mental Abuse by Social Services Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from mental and verbal abuse by staff, as required by its Abuse Prevention and Reporting Policy and Resident Rights Policy. The facility’s policies define abuse as the willful infliction of intimidation, punishment, or mental anguish, and specifically describe mental and verbal abuse as conduct that can cause humiliation, intimidation, fear, shame, agitation, or degradation. The policies also require staff to treat residents with courtesy, professionalism, and respect at all times, and emphasize staff training on resident rights, what constitutes abuse, and the obligation to report suspected abuse. The incident centers on one resident with multiple medical and psychosocial conditions, including anxiety disorder, depression, hepatic encephalopathy, psychoactive substance abuse, vertebral disc degeneration with discogenic back pain, heart failure, liver disease, fall history, abnormal gait, lack of coordination, abnormal posture, impaired visual function, and a care plan identifying an activities of daily living performance deficit and risk for abuse/neglect. The resident’s care plan notes that the resident is at risk for abuse/neglect and is to be cared for in a safe manner and to verbalize any incidences of abuse or neglect. On the day of the incident, a CNA delivered the resident’s lunch tray, and the resident requested a salad. The CNA went to the kitchen, found it closed, and reported back that a salad was not available. The resident became angry, told the CNA to get out of the room, and, according to staff statements, called the CNA derogatory names, including “piece of s***,” and allegedly threw a tray. The CNA then informed the Social Service Director that the CNA did not want to return to the room alone. The Social Service Director then went to the resident’s room. According to multiple staff and resident statements, the Social Service Director approached the resident with an angry attitude, got very close to the resident’s face, and used profane and degrading language. A Certified Occupational Therapy Assistant, who was in the bathroom providing therapy to the roommate, reported overhearing the Social Service Director tell the resident, “You have to quit being an a****** to my staff,” and that the Social Service Director argued with the resident, stating the resident could go get their own salad and could not yell at staff, emphasizing that the CNA was the only CNA on the unit. The COTA described the Social Service Director as aggressive, rude, and berating, using “a lot of other bad words,” and reported that the resident was very upset. The Director of Nursing reported being told by the COTA that the Social Service Director told the resident, “do not be a f****** a****** to my staff,” and immediately reported this to the Administrator. The resident stated that they had an “explosive attitude” and acknowledged not being nice to the CNA, but reported that the Social Service Director came into the room right after the conflict with the CNA, got inches from the resident’s face, and was “cussing and screaming,” telling the resident to “f*** off” and calling the resident an “a******.” The resident reported feeling belittled, humiliated, helpless, and like an “idiot,” and expressed that the Social Service Director, who was supposed to help with discharge planning, instead degraded them. Other staff, including the Therapy Director and Resident Council President, reported hearing that the Social Service Director had been fired for cursing at the resident and described prior concerns and complaints about the Social Service Director’s behavior toward residents and staff. The facility’s own final abuse investigation documented that the Social Service Director was overheard telling the resident not to be an “a******” to staff and acknowledged unprofessional conduct by cursing during the conversation, although the facility’s internal conclusion stated that verbal abuse did not occur. These actions and interactions, as documented by multiple witnesses and the resident, constitute the basis for the cited deficiency related to failure to protect the resident from mental and verbal abuse.
Failure to Employ a Dietary Manager Resulting in Ongoing Food and Menu Problems
Penalty
Summary
The deficiency involves the facility’s failure to employ a certified Food Service Manager/Dietary Manager as identified as necessary in its own Facility Assessment Tool and Dietary Manager job description. The assessment specifies that a Food Service Manager/Dietary Manager is needed to care for the resident population, and the job description outlines responsibilities such as planning, organizing, developing, and directing the Food and Nutrition Services Department, maintaining menus, participating in survey inspections, and possessing Food Service Sanitation Manager Certification. Despite these documented requirements, the facility census showed 63 residents on 12/24/25, and on multiple survey dates (12/27/25, 12/28/25, and 12/29/25) the facility could not identify or provide evidence of an employed Food Service Manager/Dietary Manager, nor a contact person for that role. The employee contact list also documented “Dietary Manager none.” Resident Council minutes from two separate meetings documented that the facility was looking for a new Dietary Manager, that the DON was handling dietary questions, and that there was no Food Committee meeting due to the absence of a manager. Multiple staff interviews confirmed that the former Dietary Manager had left about two months earlier and that no replacement had been hired. The DON stated that the facility did not currently have a Dietary Manager and that she helped out in the department when she could, while dietary staff reported that they “all just pitch in,” with certain cooks handling “a lot of the kitchen stuff” and one cook stating that they “pretty much do everything” in the kitchen because there had been no manager since the former manager left. The contracted registered dietician and the ombudsman both corroborated that the facility was still looking for a Dietary Manager and had not hired one. Multiple alert and oriented residents reported ongoing problems with food quality and service during the period without a Dietary Manager. The Resident Council President stated that there had not been a kitchen manager for a long time and described the kitchen as run “terrible,” with menus not matching what was served and food being cold and undercooked. Other residents reported that they did not receive what was on the posted menu, that food was “not edible,” undercooked, cold, and sometimes consisted only of carbohydrates without fruit or vegetables. Several residents stated that the facility frequently ran out of coffee and milk, that salads were brown, mushy, and slimy, and that they could not obtain requested items such as turkey sandwiches. One resident on a special diet reported not receiving what they were supposed to get and inadequate assistance when requesting alternatives, and another diabetic resident reported insufficient evening snacks. Staff, including the MDS RN/manager on duty, acknowledged hearing resident complaints that the food was terrible and that the posted menu was not followed.
Failure to Follow Planned Menus and Provide Nutritionally Appropriate Meals
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned, dietician-reviewed menus and ensure that meals met residents’ nutritional needs as required by policy and facility assessment. The facility’s assessment tool identified the need for a Food Service/Dietary Manager to ensure appropriate food services and menus. Facility policies and the Dietary Manager job description required that menus be planned in advance, maintained, followed, and that residents be offered items from the planned menu. Resident Council minutes over several months documented ongoing dietary concerns, including removal of available off‑menu options, lack of a Dietary Manager, and complaints that substitutes were becoming regular meals instead of true alternatives. Surveyor observations on specific dates showed that posted menu items were not served as planned. The week-at-a-glance menu listed western egg bake with ham for breakfast and baked potato with sour cream and margarine for lunch on a specific date, but the western omelet served that morning contained no ham, and residents at lunch received sweet potatoes instead of baked potatoes. Multiple alert and oriented residents reported that the menu was frequently not followed, that food was cold, undercooked, or not edible, that there was often no choice, and that they did not receive what was listed on the menu or what their special diets required. Residents also reported frequent lack of milk and coffee, inability to obtain requested items such as turkey sandwiches, brown and slimy salads, meals composed only of carbohydrates without fruit or vegetables, and inadequate evening snacks for a resident with diabetes. Staff interviews confirmed that the facility had been without a Dietary Manager for about two months, with the DON informally overseeing the department and dietary staff “pitching in” without clear management. Dietary staff and the contracted dietary supplier reported ongoing problems obtaining and managing ingredients needed to follow the menus, frequent running out of key items such as milk and ham, and corporate-driven budget constraints that led to cutting orders and improvising menu items. The contracted supplier noted that ham supplies were depleted after a Christmas potluck, leaving no ham for the planned western omelet, and that sweet potatoes were substituted for baked potatoes due to lack of regular potatoes. Staff also described poor portion control and failure to properly use or prepare produce such as lettuce, contributing to food waste and further deviation from the planned menus. These actions and inactions resulted in the facility not following its posted menus and not consistently providing the planned, nutritionally appropriate meals to its 63 residents.
Failure to Identify and Substantiate Verbal Abuse Toward a Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and substantiate verbal and mental abuse toward a resident in accordance with its Abuse Prevention and Reporting Policy. The policy defines abuse as including willful mental abuse and verbal abuse, such as harassing, insulting, yelling, or threatening a resident, and requires staff to promptly investigate and report all allegations. An incident occurred involving the former Social Service Director (V4) and a resident (R1) after R1 became upset when a Certified Nursing Assistant (V17) could not obtain a requested salad because the kitchen was closed. R1 reacted by telling V17 to get out of the room, calling V17 derogatory names, and allegedly throwing a tray. V17 then reported to V4 that V17 did not want to return to R1’s room alone. Multiple staff and the resident provided statements describing V4’s subsequent interaction with R1. The Certified Occupational Therapy Assistant (V13), who was in the bathroom providing therapy to R1’s roommate, reported overhearing V4 approach R1’s bedside with an attitude, get close to R1’s face, and berate R1 using profanity, including calling R1 an “a******” and telling R1 not to be a “f****** a******” to staff. V13 stated that V4 was aggressive, rude, and degrading toward R1 and immediately reported the incident to the Director of Nursing (V2). R1’s own written and verbal statements corroborated that V4 entered the room right after the conflict with V17, got inches from R1’s face, screamed and cursed, told R1 to “f*** off,” and called R1 an “a******,” which R1 described as belittling, humiliating, and degrading. Despite these statements, the facility’s Final Abuse Investigation, completed by the former Administrator/Abuse Coordinator (V18), concluded that verbal abuse did not occur and characterized V4’s conduct only as unprofessional use of profanity not directed at the resident. The investigation documented that V4 used profane language during the conversation but did not substantiate abuse, even though staff statements and R1’s account indicated cursing and degrading language directed at R1. V2 later stated that, based on the information and statements collected, V4 did mentally and verbally abuse R1 and that the investigation could have reached a more thorough determination by substantiating the abuse. The failure to recognize and substantiate this conduct as abuse, despite corroborating evidence, represents the facility’s failure to follow its own abuse policy and to properly identify abuse for one of three residents reviewed for abuse investigations.
QA Committee Meetings Lacked Required Attendance and Documentation
Penalty
Summary
The facility failed to conduct quarterly Quality Assurance/Quality Assurance Performance Improvement meetings with the required committee members present. The facility’s CMS 671 form, dated 9/23/25, documented 61 residents in the building. The QA/QAPI policy, revised 10/24/22, required an organized quality assessment and improvement process, quarterly committee meetings, and maintenance of minutes, related reports, and attendance in the Administrator’s office. Review of QAPI meeting minutes for 12/4/24, 2/12/25, 4/9/25, 5/27/25, 6/11/25, 7/9/25, and 9/11/25 did not document the Medical Director’s attendance, and the facility could not provide minutes for March 2025. During interview on 9/24/25 at 9:54 AM, the Administrator stated that QA meetings were held every month and that the Medical Director was filled in when present in the building because it was difficult to coordinate the meeting dates with the Medical Director’s schedule.
Failure to Monitor Water System for Legionella
Penalty
Summary
Provide and implement an infection prevention and control program. Based on interview and record review, the facility failed to test for the presence of Legionella throughout the facility's water system. The facility's Resident Roster dated 9/23/25 documented 61 residents residing in the facility. The facility's Water Management Program for Prevention of Legionella Growth, revised on 6/27/23, stated that the domestic hot water boiler and storage tanks were to be verified and documented at least once weekly and set between 140 - 160 degrees F, and that the thermostat indicating the temperature of water entering the circulating system at the mixing valve was to be 120 F or above. On 9/25/25 at 1:10 pm, the Maintenance employee stated the facility does not have a boiler and uses a hot water heater to heat the facility's incoming water, and that the Maintenance Department does not keep a weekly log documenting the hot water heater temperatures.
Unjustified Antipsychotic Use
Penalty
Summary
The facility failed to justify the use of an antipsychotic medication for one of five residents reviewed for unnecessary medications. The resident was admitted with a diagnosis of Severe Vascular Dementia with Agitation, and the physician order sheet included Quetiapine Fumarate 150 mg by mouth at bedtime related to Vascular Dementia, Severe, with Agitation. The resident’s monthly MARs for the past 3 months documented that Quetiapine was administered as ordered, and the medical record included progress notes from the facility’s contracted psychiatric provider documenting the order for Quetiapine for the diagnosis of Severe Vascular Dementia with Agitation. The facility’s DON verified that the resident’s diagnosis of Severe Dementia with Agitation did not justify the use of Quetiapine, an antipsychotic.
Failure to Notify Representatives and Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The Facility failed to notify Resident Representatives of transfers/discharges and the reason for discharge and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for two residents reviewed for transfer and discharge. Facility policy, revised 9/26/17, states that residents and/or representatives are to be notified of the Facility Bed Hold Policy and conditions for return to the Facility upon admission and at the time of transfer, and that the Bed Hold Policy will be given to the resident or resident representative at the time of transfer. For R4, the record shows an unwitnessed fall on 5/24/25 followed by transfer to the local Emergency Department for evaluation. The Bed Hold Policy Notice dated 5/24/25 documents the transfer out of the Facility, but it does not document the reason for discharge or notification to the Resident Representative. For R8, the record shows diagnoses including left femur fracture, epilepsy, anxiety, depression, COPD, acute respiratory failure, and peripheral vascular disease, and documents a post-fall transfer to the local Emergency Department. The Bed Hold Policy Notice dated 5/11/25 states the resident was unable to sign at the time of transfer and does not document that a copy was mailed to the Representative; it also does not document the reason for discharge or notification to the Resident Representative. The Facility Ombudsman Notification of Discharge/Transfer Log and Discharge/Transfer Log do not document R8's 5/11/25 discharge.
Failure to Update Care Plan After Hospice Discharge
Penalty
Summary
The facility failed to revise the care plan for one resident after changes in the resident’s status. The resident was admitted with diagnoses including COPD, respiratory failure, chronic pain, neuropathy, vascular dementia, seizures, bilateral foot and ankle contractures, dysphagia, bipolar disorder, and depression. The census report showed the resident returned to the facility from a hospitalization with Hospice services and was later discharged from Hospice services. The resident’s care plan still documented that the resident required communication and contact assistance with Hospice, that staff were to notify Hospice of any changes in condition, and that the resident needed a discharge plan and bereavement care. The facility’s Comprehensive Care Plan policy stated the care plan must describe the services being furnished and be reviewed and revised by the interdisciplinary team on an ongoing basis to reflect changes in the resident’s care. The DON confirmed the resident had been discharged from Hospice and the care plan should have been updated.
Failure to document acute change in condition and provide ordered wound care
Penalty
Summary
The facility failed to ensure a resident received a nursing assessment and timely provider notifications during an acute change in condition. R28, who had diagnoses including dyspnea, hypertension, anemia, myocardial infarction, ventricular tachycardia, major depressive disorder, congestive heart failure, atrial fibrillation, sleep apnea, renal dialysis, and type II diabetes mellitus, was transferred to the hospital, but the progress note did not document the time of transfer, the resident’s condition, the interventions that led to the transfer, or whether the physician and/or resident’s representative was notified. The record also did not include the required hospital transfer details, and the Director of Nursing confirmed the record lacked an assessment and documentation of the events surrounding the transfer. The facility also failed to ensure wound care was provided as ordered for R6. R6 had a chronic wound to the right groin, and the physician ordered Clindagel topical gel to be applied every day and night shift for wound care. The record showed the medication was unavailable and on order, with staff notes indicating the physician/nurse practitioner was notified, but the TAR contained staff signatures indicating treatments were completed on shifts when the treatment had not actually been provided. The resident stated the groin treatments were supposed to be done twice daily but often were not completed, and the LPN acknowledged signing the TAR before the treatment was done, while the DON stated nurses are expected to document only after the treatment is given.
Failure to Monitor Weights and Clarify Diet Orders
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met when the facility failed to obtain daily weights, notify the physician of ordered weight gains, and monitor for weight discrepancies for one resident. The resident had diagnoses including HTN, depression, anxiety, lymphedema, OSA, DM, and CHF. A physician order required daily weights and notification if weight gain exceeded 3 lbs in a day or 5 lbs in a week, but the weight summary showed 32 of 77 days without documented daily weights during the reviewed period. The record also showed multiple weight fluctuations ranging from 3 lbs to 13 lbs, including gains of 13 lbs, 7 lbs, 7 lbs, 10 lbs, and 5 lbs, with no documentation that the physician was notified or that the resident was re-weighed when the change was greater than 5 lbs. The facility also failed to clarify diet orders before feeding another resident. That resident had diagnoses including COPD, respiratory failure, chronic pain, neuropathy, vascular dementia, seizures, bilateral foot and ankle contractures, dysphagia, bipolar disorder, and depression. The care plan and physician order documented a no added salt, mechanical soft, thin liquid diet, while hospital discharge information and hospice documentation reflected a regular or general diet as tolerated after the resident failed a swallow evaluation and returned with hospice services. The resident stated he wanted to speak with speech therapy and reported that staff were making him eat "dog food" and would not provide requested foods such as egg salad, tuna salad, ham salad, ravioli, and meatloaf. The dietary manager stated the resident should be on a pureed diet because he had no teeth, while the administrator confirmed the diet order should have been clarified so food preferences could be honored and provided as requested.
Nebulizer Equipment Not Dated per Order
Penalty
Summary
The facility failed to ensure oxygen equipment was maintained according to physician's orders for one resident receiving nebulizer treatments. The resident was admitted with diagnoses including hypertension, depression, anxiety, lymphedema, obstructive sleep apnea, diabetes mellitus, and congestive heart failure. The physician's order directed staff to change out, date, and label the nebulizer mask and tubing weekly and as needed when in use, and the facility policy stated the handheld nebulizer should be changed weekly and as needed. The resident's MAR documented daily nebulizer treatments, but during observation the nebulizer mask and tubing were not labeled with a date showing when they had been changed. An LPN later confirmed that oxygen equipment should be dated.
Failure to Track and Justify Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to log, track, and justify the prophylactic use of an antibiotic with no stop date for one resident, R39, who was reviewed for antibiotic use. R39’s record showed admission with diagnoses including cerebral palsy, type 2 diabetes, morbid obesity, schizophrenia, follicular disorder, and idiopathic progressive neuropathy. The facility’s Infection Prevention and Control Program policy stated that antibiotic use would be logged and tracked to monitor prescribing practices and outcomes, and that prophylactic long-term antibiotic use would be discouraged unless clinical rationale was provided. R39’s POS included an order from the Medical Director for doxycycline monohydrate 100 mg daily for infection related to follicular disorder, marked as prophylactic with no stop date. However, there was no documentation of this ongoing prophylactic antibiotic use in the facility’s monthly Infection Logs for July 2025, August 2025, or September 2025, and no physician justification was provided for the open-ended use. The DON stated she was aware of the order and verified the lack of infection log documentation and physician justification.
Improper Transfer Technique Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to its policy of using a gait belt for all physical assist transfers, which resulted in a resident falling and injuring her left wrist. The incident involved a CNA who attempted to assist the resident off the toilet by grabbing her bra instead of using a gait belt, leading to the resident losing her balance and falling to the bathroom floor. This action was contrary to the facility's documented procedures, which mandate the use of a gait belt for all transfers to ensure resident safety. The resident involved in the incident had a history of a previous wrist fracture and required assistance with toileting due to mobility limitations. At the time of the incident, the resident was being assisted by the CNA, who was reportedly in a hurry and did not follow the proper transfer protocol. The resident's care plan indicated a risk for falls and injury, highlighting the importance of following established safety procedures during transfers. Following the fall, the resident was transported to the hospital, where X-rays confirmed an acute fracture of the left wrist. The resident was subsequently prescribed a wrist splint and pain medication. The facility's failure to use a gait belt during the transfer and the improper handling by the CNA directly contributed to the resident's fall and subsequent injury.
Failure to Employ Certified Infection Prevention Nurse
Penalty
Summary
The facility failed to employ a certified Infection Prevention Nurse, which has the potential to affect all 62 residents residing in the facility. The Administrator stated that an Infection Prevention Nurse was hired, but she is not yet certified. Although the nurse is signed up for the necessary courses, she has not started them. The nurse was hired in October 2024 and began work on October 29, 2024. A review of her employee file confirmed the hire date but showed no certification or Infection Preventionist Training documentation.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care for a resident. A registered nurse (RN) was observed preparing to perform wound care on a resident who had a bowel movement. The RN, while wearing clean gloves, removed the resident's stool-covered wound dressing and placed it in the soiled incontinence brief, which was then placed on the floor. The RN, still wearing the same soiled gloves, touched the door handle and accepted clean linens from a certified nursing assistant (CNA), thereby contaminating clean items. The RN continued to provide incontinence care to the resident without changing the soiled gloves, further compromising infection control protocols. The RN later stated that she was unaware that she should not touch clean items with soiled gloves and typically placed dirty incontinence briefs on the floor if a trash can was not available. This incident highlights a breach in the facility's infection prevention and control program, which aims to prevent and control infections among residents and staff.
Failure to Conduct Required QA Meetings and Ensure Attendance
Penalty
Summary
The facility failed to conduct the required quarterly Quality Assurance meetings and did not ensure the attendance of the required Quality Assurance committee members. Specifically, the Quality Assurance Performance Improvement Meeting Minutes attendance sign-in sheets were missing signatures from key members such as the Medical Director and Director of Nursing Services for meetings held in April 2023 and April 2024. Additionally, there were no available meeting minutes for July 2023, October 2023, and January 2024. The facility's policy mandates that the Quality Assessment and Assurance Committee meet at least quarterly and include specific members such as the Medical Director, Director of Nursing Services, and other key personnel. The Administrator confirmed the missing signatures and the absence of meeting minutes for the specified months. These failures have the potential to affect all 63 residents currently residing in the facility.
Inadequate PPE Use and COVID-19 Screening During Outbreak
Penalty
Summary
The facility failed to utilize appropriate PPE, audit for PPE compliance, and screen staff during a COVID-19 outbreak, potentially affecting 63 residents. The facility's Infection Control-Interim COVID-19 policy required the use of NIOSH-approved N95 respirators, gowns, gloves, and eye protection for healthcare providers entering rooms of residents with suspected or confirmed COVID-19. However, observations revealed that staff, including agency CNAs and registered nurses, did not consistently adhere to these guidelines. For instance, an agency CNA entered a resident's room without properly tying the gown, and a registered nurse entered another resident's room without any PPE. Additionally, residents with confirmed COVID-19 were observed wandering the halls without proper PPE, and staff failed to redirect them effectively. The facility also failed to ensure the availability of NIOSH-approved PPE. PPE supply cabinets contained non-approved KN95 masks, which were used by staff entering COVID-19 isolation rooms. The Infection Control Preventionist admitted to not conducting PPE audits and only monitoring hand hygiene compliance. Furthermore, the facility did not include agency staff in COVID-19 source testing, despite having multiple agency staff working during the outbreak. This omission was confirmed by both agency CNAs and the Infection Control Preventionist, who acknowledged that excluding agency staff from testing skewed the sampling and was not all-inclusive. Specific incidents included a registered nurse entering a resident's room on droplet precautions with only a surgical mask and face shield, failing to don full PPE, and not changing the mask after exiting. The facility's documentation showed that 63 residents resided in the facility at the time of the survey. These deficiencies highlight significant lapses in infection control practices, particularly during a COVID-19 outbreak, putting residents and staff at risk of infection.
Failure to Provide Clean Linens for Bathing
Penalty
Summary
The facility failed to provide clean, stain-free linens for bathing for nine residents, compromising their dignity and self-worth. Observations and interviews revealed that residents were given discolored washcloths with brown/tan stains for personal hygiene. One resident expressed disgust at the stained washcloths, stating it was undignified and unsanitary. Another resident was upset about being given a filthy washcloth to wash her face and mentioned being asked to use a blood-stained towel on a community shower chair. The Housekeeping Manager confirmed that stained linens were supposed to be repurposed for housekeeping or kitchen use, but soiled washcloths were observed in the laundry bin ready for washing with other whites. The Resident Council President and other residents voiced concerns about being demeaned by using feces-stained washcloths for bathing. During a group meeting, multiple residents agreed that the stained washcloths were demeaning. The facility's Administrator acknowledged the policy change to no longer provide disposable wipes for incontinence care, requiring staff to use washcloths instead. The Administrator stated that staff were not supposed to use stained washcloths and would remind the laundry staff to discard them.
Failure to Perform PASARR Rescreen for Resident with Severe Mental Illness
Penalty
Summary
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 reviewed for PASARR screening, in the sample of 30. The facility's policy mandates that PASARR Level 1 screens be completed annually and with any significant change of status. Resident 2 (R2) was admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder, but the current PASARR screen provided by the Director of Nurses indicated no diagnosis of Severe Mental Illness at the time of the original admission. The Director of Nurses confirmed that R2 had not undergone a PASARR rescreen upon admission to the facility, despite the severe mental illness diagnoses.
Failure to Ensure Safe Transport Leading to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was safely transported in the facility's transport van, resulting in a fall. The incident involved a resident with diagnoses including dependence on a wheelchair, diabetes mellitus with diabetic autonomic neuropathy, and an acquired absence of the left leg. The resident fell in the transport van while en route to a doctor's appointment. The fall investigation revealed that the resident was not wearing his wheelchair seatbelt, and the van's lap belt was too loose, allowing the resident to slip forward out of his wheelchair when the van came to a stop. The van driver, who was new to the job, admitted to loosening the seatbelt at the resident's request because it was uncomfortable, which contributed to the fall. During a group meeting, the resident recounted the fall and the subsequent pain in his right leg, which required evaluation at a local hospital emergency room. The resident also mentioned that he was not sitting in his usual spot in the van due to another resident being transported. The van driver confirmed the details of the incident, acknowledging that the seatbelt should have been much tighter and that he now understands the importance of ensuring seatbelt safety. The facility's fall risk care plan was updated to include educating the bus driver and resident on seatbelt safety while in a wheelchair.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed Seroquel, an antipsychotic medication, within the first year of its prescription. The facility's policy mandates that residents on psychotropic drugs should receive GDRs and behavioral interventions unless clinically contraindicated, with GDRs encouraged at least twice yearly. However, for one resident with multiple diagnoses including Major Depressive Disorder, Generalized Anxiety Disorder, and Dementia, the facility did not attempt a GDR despite the resident being on the same dose of Seroquel for a year. The resident's behavior monitoring sheets documented minimal episodes of agitation, anxiety, and restlessness, which did not justify the continued use of the antipsychotic medication according to the Director of Nursing (DON). The DON confirmed that the resident's behaviors did not warrant the use of Seroquel and acknowledged that a GDR had not been attempted. During an interview, the resident expressed that he was doing well at the facility and was in the process of applying for disability with plans to discharge and live independently. The resident did not display any adverse behaviors during the observation. The DON stated that loud noises could trigger and agitate the resident but confirmed that the resident was not a harm to himself or others. Despite this, the facility did not follow its policy to attempt a GDR, leading to the deficiency noted in the report.
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What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Toluca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Henry Rehab And Nursing | 13.9 mi | ★★★★★ | 0 | 0 |
| Lacon Rehab And Nursing | 14.5 mi | ★★★★★ | 7 | 1 |
| Apostolic Christian Home | 15.5 mi | ★★★★★ | 8 | 0 |
| Flanagan Rehabilitation And Health Care Center | 15.5 mi | ★★★★★ | 3 | 0 |
| Parker Nursing & Rehab Center | 17.5 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.