Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Falls are often caused by leaving a resident unattended; leaving a resident in the bathroom
without supervision; and failing to use gait belt when transferring or ambulating a resident.
Facility Safety Belt Policy, dated 8/10/24 and signed by V5 CNA/Certified Nurse Aid documents All staff that
assists residents with ambulation and/or transfers will use a safety belt as indicated to promote safety for
the resident and staff. I have received a safety belt from the facility, and I have my own safety belt. V5
CNA/Certified Nurse Aid Employee File documents V5 was hired on 8/2/24.
R1's Incident Report, dated 12/19/24, documents the following: (R1) was being toilet by the CNA (V5). (R1)
described the CNA (V5) as hurrying to transfer which resident believes to have resulted in her fall.
Complaints of pain to left arm. Change of plane from the toilet to the floor in her bathroom. The CNA (V5)
tried to assist her off the toilet by her bra resulting in a change of plane from the toilet to the bathroom floor.
(R1) pointed to her left arm when asked if any pain. (V8) Nurse and (V5) CNA assisted (R1) off the floor
and into bed (no gait belt used). (V8) Nurse standing behind (R1) and (V5) CNA standing in front of (R1)
helped (R1) off the floor and (R1) got into bed. Terminated (V5) CNA and DNR/do not return (V8) agency
nurse due to improper transfer per facility policy while getting resident up off floor.
Facility Daily Shift Assignment, dated 12/18/24, documents V5 CNA worked from 11PM on 12/18/24 until
7AM on 12/19/24.
R1's current Care Plan with a date initiated on 4/18/24, documents I have an ADL/Activities of Daily Living
self-care/mobility performance deficit that may fluctuate with activity throughout the day. This same Care
Plan with a date initiated on 7/11/24, documents I am at risk for fall/injury
(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 3
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
12/27/2024
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 - Actual harm
Residents Affected - Few
related to wandering and poor safety awareness. CNAs/Certified Nurse Aids were re-educated on using
appropriate transfer techniques transfer/manual gait belt and mechanical lift policy when assisting or
transferring residents.
R1's Minimum Data Set/MDS, dated 12/5/24, documents R1 is partial/moderate assistance for toilet
transfer, and frequently incontinent of urine.
R1's Nurses Note, dated 12/19/2024 at 4:45AM by V8 RN/Registered Nurse, documents Nurse standing at
med cart at the nurses station preparing meds for morning med pass, heard loud crying from C wing (R1);
Fax sent to MD/Medical Doctor to inform as well as ask if x-ray for right wrist was ok.
R1's Pain Assessment, dated 12/19/24, documents Pain the left forearm, complained of pain in the left
wrist, previous fracture, and received pain medication. R1's Progress Note, dated 12/16/2024 documents
(R1) is a [AGE] year-old female presented to the OT/Occupation Therapy department due to (R1) recently
had a cast from LUE (left upper extremity) wrist/forearm removed and returned from MD/Medical Doctor
with orders to address left wrist ROM/Range of Motion and strengthening - no restrictions per MD note.
R1's X-Ray, dated 12/19/2024, documents Acute comminuted, slightly dorsally impacted fracture of the
distal radial epiphysis with resultant slight positive ulnar variance.
R1's X-Ray, dated 12/21/24, documents History of left wrist fracture status post fall 12/19/24. Intra-articular
distal radial fracture with re-demonstrated dorsal impaction. Acute chronic non-displaced fracture is difficult
to exclude by imaging and clinical correlation is advised.
R1's After Visit Summary, dated 12/21/24, documents R1 had a fall with an arm injury and diagnosed with
left wrist pain; follow up appointment on January 13, 2025, at 8:30AM with an Orthopedic office; and
instructions to Wear Velcro splint as tolerated. Continue with over-the-counter pain medication if needed.
Follow up with Orthopedics for a recheck as needed.
R1's medication record, dated 12/22/24, documents R1 was prescribed Tylenol 650 mg/milligrams by
mouth every six hours as needed for pain.
R1's Progress Note, dated 12/23/2024 by V6 APRN/Advanced Practice Registered Nurse, documents (R1)
was seen on this day for a follow-up visit. (R1) has had a recent fall on 12/20/24, that resulted in Left
wrist/forearm discomfort. (R1) had had a previous injury to her left wrist/forearm are that resulted in two
fractures - previous x-ray results from 8/30/24 revealed a non-displaced fracture of the ulnar styloid and a
comminuted intra-articular fracture of the distal radius. (R1) had a follow-up x-ray on 12/19/24 that had
similar results to the x-ray completed in 8/2024 - this result includes a dorsally impacted, intra-articular
fracture of the distal radius, and stated to have no comparison exam. The fracture was not stated to be new
or healing. (R1) was sent to local ER/emergency room on [DATE] where an additional x-ray was completed.
This x-ray revealed the intra-articular distal radial fracture that was stated to have re-demonstrated dorsal
impaction.
On 12/26/24 at 11:50AM, R4 (R1's roommate) was alert and oriented and stated (V5 CNA) toileted (R1) on
12/19/24. (R1) needs help wiping herself, she goes to the bathroom a lot about 2-3 times an hour, and the
staff gets impatient. (V5) took her in the bathroom to toilet, she fell somehow with (V5), but I couldn't see
everything because the bathroom door was partially closed but I could hear a commotion of voices in the
bathroom, and now (R1's) arm is in a brace. (R1) said (V5) made her fall.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 2 of 3
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
12/27/2024
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 - Actual harm
Residents Affected - Few
On 12/26/24 at 12PM, V7 LPN/Licensed Practical Nurse stated I worked midnights until December 2024.
(R1) she needs assistance with toileting because she wears a pull up and needs assistance wiping her
behind because her arms are too short.
12/26/24 at 12:10PM, V3 RN/MDS/Interpreter stated (R1) had a fracture of her left arm a few months back.
On 12/19/24 (R1) stated (V5 CNA) toileted her, (V5) grabbed her bra in the front of her that she was
wearing to help her off the toilet and she fell on her hands and knees and hurt her left wrist. (V5) left the
room after (R1) screamed and went to get the nurse.
On 12/26/24 at 12:15PM, R1 was interviewed through V3 RN (Registered Nurse)/MDS (Minimum Data
Set)/Translator due to R1 Spanish speaking only. At that time, R1 confirmed the following: she fell when in
the bathroom with V5 CNA when V5 CNA assisted R1 off the toilet by her bra and R1 lost her balance and
went down on the bathroom floor on her hands and knees; R1 needs assistance with toileting and wiping
herself; V5 CNA did not use a gait belt to get her on/off the toilet; and V5 CNA and V8 RN/Registered Nurse
did not use a gait belt to get her off the floor. At that same time, R1 was observed wearing a brace to her
left wrist and stated her left wrist hurts.
On 12/26/24 at 12:45PM, V1 Administrator stated (V5 CNA) was terminated and the agency nurse was
DNR due to not following our transfer policy (on 12/19/24). When asked if due to no gait belt used V1
nodded and stated Yes they did not use a gait belt to get (R1) off the floor and that is our policy for
transfers. (V5) was trying to get (R1) dressed for the day and (V5) transferred her off the toilet. (V8) had
already heard (R1) scream and start crying and saw (V5) come out the adjoining bathroom door. (R1) had
fallen and broke her left wrist prior. Her wrist was healing, and she was not wearing the brace anymore.
(R1) came to the nursing home in September 2024.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145413
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the December 27, 2024 survey of GOLDWATER CARE TOLUCA?
This was a inspection survey of GOLDWATER CARE TOLUCA on December 27, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GOLDWATER CARE TOLUCA on December 27, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.