The incident occurred during lunch on October 29 at Wheaton Franciscan Healthcare - Terrace at St. Francis, where federal inspectors witnessed a dangerous breakdown in fall prevention protocols.
Resident 6, identified as a fall risk requiring toilet assistance after meals, had transferred herself onto the toilet without help. Her roommate, Resident 7, was in the shared room when nursing assistant CNA-N entered at 12:52 p.m.
CNA-N noticed the bathroom door was closed. She placed candy on the bedside table for Resident 7, told the inspector this was "usual behavior" for the resident, and asked if Resident 7 wanted something to drink.
She left without checking the bathroom.
Four minutes later, CNA-N returned with coffee for Resident 7. Only then did she open the bathroom door, discovering Resident 6 sitting on the toilet with her wheelchair positioned nearby and a New Testament book resting on the handrail.
The nursing assistant put on gloves, announced she needed to get a gait belt, and left Resident 6 alone on the toilet again. When she returned with the belt and tried to help the resident stand, asking "are you going to help me?" Resident 6 replied, "I don't know."
CNA-N then abandoned the effort and left the bathroom once more.
At 1:00 p.m., nearly ten minutes after the initial discovery, CNA-N returned with a second nursing assistant, CNA-K. Together they placed an incontinence product on Resident 6, told her they would stand her up to clean her, and completed the toileting process.
After seating Resident 6 in her wheelchair, CNA-N issued a stern warning: "I don't want you to do any more self-transfers. Do not put yourself on toilet." She handed the resident her New Testament, wheeled her out of the bathroom, showed her the call light, and instructed her to use it next time instead of going to the bathroom herself.
The facility's Licensed Practical Nurse and Interim Unit Manager confirmed to inspectors that Resident 6's fall intervention plan required toileting "right after meal." The care plan details were supposed to be updated on staff care cards so nursing assistants would know to provide this assistance.
But on this day, nobody took Resident 6 to the toilet after lunch. She transferred herself, sitting alone and potentially unsafe while staff focused on her roommate's refreshments.
Eight minutes after the toileting incident concluded, the facility chaplain wheeled Resident 6 out of the room for religious services, unaware of what had transpired.
The violation represents actual harm to residents, according to federal inspectors who classified it under regulations requiring nursing homes to ensure each resident receives care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Fall prevention plans exist because self-transfers pose serious injury risks for vulnerable residents. When a resident identified as needing post-meal toilet assistance instead navigates this process alone, the consequences can extend far beyond a single incident.
Resident 6's case illustrates how care plan failures cascade through a facility's daily operations. Her roommate received prompt attention for minor comfort needs while she sat unassisted in a potentially dangerous situation, exactly what her individualized care plan was designed to prevent.
The facility provided no additional information about the incident when questioned by inspectors.
For Resident 6, the afternoon ended with a warning not to transfer herself again, despite the fact that staff had failed to follow the very protocols designed to make such warnings unnecessary.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wheaton Franciscan Hc - Terrace At St Francis from 2025-10-29 including all violations, facility responses, and corrective action plans.
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