Goldwater Care Toluca

In the surveyor’s words

From the most serious findings on record at Goldwater Care Toluca, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 18, 2026

  Based on interview and record review, the facility failed to provide supervision for a resident at risk for falls for one of three residents (R3) reviewed for falls in a sample of six. This failure resulted in R3 falling and sustaining a left intertrochanteric proximal femur fracture requiring surgical intervention. This past noncompliance occurred from 4/18/26 through 4/24/26. Findings include: The facility's Fall Prevention Program, revised 11/21/17, documents to assure the safety of all residents in the facility when possible. […]

• Actual harm, isolatedF600Dec 30, 2025

  Based on interview and record review, the Facility failed to protect Residents' Rights to be free of Mental Abuse and Verbal Abuse from a Facility staff perpetrator that caused mistreatment, emotional distress, and mental anguish for one of three Residents (R1) reviewed for Abuse in a sample of three. Findings include:The Facility Abuse Prevention and Reporting Policy, dated 10/24/22, documents: the Facility affirms the right of our Residents to be free from abuse; the Facility prohibits abuse and mistreatment of Residents; the Facility has established a Resident sensitive and secure environment; the policy assures the Facility is doing all that is within its control to prevent occurrences of abuse; the Facility will establish an environment that promotes Resident sensitivity, security and… […]

• Actual harm, isolatedF689Dec 27, 2024

  Based on observation, interview, and record review, the facility failed to transfer a resident with a gait belt for one (R1) of three residents reviewed for accident/incidents in a sample of three. This failure resulted in R1 falling and injuring her left wrist where she was transported to the hospital, X-Rays obtained, R1 was ordered a wrist splint to be worn, and follow up appointment with an Orthopedic doctor. Findings include: Facility Transfer-Manual Gait Belt and Mechanical Lifts, revised on 1/19/18, documents Use of gait belt for all physical assist transfers is mandatory. One person transfer requires a gait belt. Facility Handbook, dated 1/2023, documents Resident Injuries and Incidents- A common cause of resident injury is falling. […]

• No harm, potential for more than minimal, widespreadF801Dec 30, 2025

  Based on observation, interview, and record review, the Facility failed to staff a certified Food Service Manager/Dietary Manager. This failure has the potential to affect all 63 Residents Residing in the Facility.Findings include: The Facility Resident Census Roster, dated 12/24/25, documents 63 Residents residing in the Facility.The Facility Assessment Tool, undated, documents: the purpose of the Assessment is to determine what resources are necessary to care for Residents competently during day-to-day operations; to provide services to the Residents of your Facility; focuses on ensuring each Resident is provided care that allows the Resident to maintain/attain their highest practicable physical, mental and psychosocial well-being; Resident population that must be taken into account when… […]

• No harm, potential for more than minimal, widespreadF803Dec 30, 2025

  Based on observation, interview, and record review, the Facility failed to follow the Facility menu. This failure has the potential to affect all 63 Residents residing in the Facility.Findings include:The Facility Resident Census Roster, dated 12/24/25, documents 63 Residents residing in the Facility.The Facility Assessment Tool, undated, documents: the purpose of the Assessment is to determine what resources are necessary to care for Residents competently during day-to-day operations; to provide services to the Residents of your Facility; focuses on ensuring each Resident is provided care that allows the Resident to maintain/attain their highest practicable physical, mental and psychosocial well-being; Resident population that must be taken into account when determining staffing and… […]