Goldwater Care Toluca

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to identify Abuse for one of three Residents (R1) reviewed for Abuse investigations in a sample of three.

Inspectors wroteBased on record review and interview, the facility failed to conduct quarterly Quality Assurance/QA Performance Improvement meetings with the required Committee Members present. This failure has the potential to affect all 61 Residents who currently reside in the facility. Findings Include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form, dated 9/23/25, documents 61 residents reside in the facility. The Facility Quality Assurance Performance Improvement (QA)/QAPI Policy, revised 10/24/22, documents: to ensure the organized quality assessment and improvement process program that includes performance measurement, performance assessment and performance improvement; [...]

Inspectors wroteBased on interview and record review, the facility failed to test for presence of Legionella throughout the facility's water system. This failure has the potential to affect all 61 residents in the facility.

Inspectors wroteBased on Interview and record review, the facility failed to justify the use of an antipsychotic medication for one of five residents (R10) reviewed for unnecessary medications in the sample of 28.

Inspectors wroteBased on record review and interview, the Facility failed to notify Resident Representatives of transfers/discharges and the reason for discharge and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for two of 15 Residents (R4 and R8) reviewed for transfer and discharge in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of 15 residents (R9) reviewed for care planning in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a nursing assessment and timely provider notifications to ensure medical interventions were received during an acute change of condition for one of three (R28) residents reviewed for change of condition, and failed to ensure wound care was provided as ordered for one of three residents (R6) reviewed for wounds in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure daily weights were obtained, notify the physician of weight gains per physician orders, and monitor for discrepancies of weights for one of three residents (R1) with daily weights and failed to clarify diet orders prior to feeding for one of three residents (R9) reviewed for diets in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was maintained per physician's order for one of three residents (R1) reviewed with oxygen in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to log, track and justify the prophylactic use of an antibiotic with no stop date for one of five residents (R39) reviewed for antibiotic use in the sample of 28.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to employ a certified Infection Prevention Nurse. This failure has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a written reason for Transfer/Discharge for four Residents (R10, R13, R16 and R59) and failed to notify the local Ombudsman of a Resident discharge for three Residents (R10, R13 and R59) of 18 reviewed for hospitalization and discharge in a sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the resident and/or the resident representative with the facility bed-hold policy upon hospital transfer for four (R10, R13, R16 and R59) of 18 residents reviewed for Transfer/Discharge in a sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to immediately report and investigate a fall for one of three residents (R35) reviewed for accidents and supervision in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to follow interventions to decrease anxiety and re-traumatization, failed to identify triggers related to history of trauma/abuse and failed to develop a comprehensive care plan to provide Trauma Informed Care for two residents (R11, R47) of five residents reviewed for Trauma Infromed Care in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to provide indication for use of an antipsychotic medication and failed to identify specific target behaviors for two residents (R24, R25) who receive antipsychotic medications with diagnosis of Dementia of three reviewed for unnecessary psychotropic medications in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to have the State Survey Book in a place readily accessible to residents, family members, and legal representatives of residents. This has the potential to affect all 63 residents living in the facility.