Goldwater Care Toluca
101 East Via Ghiglieri · Toluca, IL · 61369 · 8154522367
104 certified beds For profit - Corporation Chain: Goldwater Care
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection results are getting worse cycle over cycle, not better.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.10 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.65 | 0.55–0.75 |
| Weekend hours / resident-day | 2.85 | ≈ weekday level |
| Nursing turnover / year | 52% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (28 in the current record)
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Actual harm · G December 30, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 31, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 30, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected December 31, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F December 30, 2025 · found via complaint
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected December 31, 2025 · Nutrition and Dietary
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Potential for harm · F December 30, 2025 · found via complaint
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected January 24, 2026 · Nutrition and Dietary
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Actual harm · G December 27, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 30, 2024 · Quality of Life and Care
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Potential for harm · D December 10, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 12, 2024 · Infection Control
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Potential for harm · F December 10, 2024 · found via complaint
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected December 14, 2024 · Infection Control
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Potential for harm · E May 2, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 8, 2024 · Resident Rights
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Potential for harm · D May 2, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected May 8, 2024 · Resident Assessment and Care Planning
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Potential for harm · D May 2, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 8, 2024 · Quality of Life and Care
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Potential for harm · D May 2, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected May 8, 2024 · Pharmacy Service
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Potential for harm · F May 2, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected May 8, 2024 · Administration
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Potential for harm · F May 2, 2024
Provide and implement an infection prevention and control program.
Corrected May 8, 2024 · Infection Control
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Potential for harm · E May 12, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected May 26, 2023 · Resident Rights
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Potential for harm · E May 12, 2023
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected May 26, 2023 · Resident Rights
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Potential for harm · D May 12, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 26, 2023 · Quality of Life and Care
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Potential for harm · D May 12, 2023
Provide care or services that was trauma informed and/or culturally competent.
Corrected May 26, 2023 · Quality of Life and Care
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Potential for harm · D May 12, 2023
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected May 26, 2023 · Pharmacy Service
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No harm found · C May 12, 2023
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected May 26, 2023 · Resident Rights
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Potential for harm · E May 11, 2022
Reasonably accommodate the needs and preferences of each resident.
Corrected June 10, 2022 · Resident Rights
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Potential for harm · D May 11, 2022
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected June 10, 2022 · Resident Assessment and Care Planning
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Potential for harm · D May 11, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 10, 2022 · Quality of Life and Care
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Potential for harm · D May 11, 2022
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected June 10, 2022 · Quality of Life and Care
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Potential for harm · D May 11, 2022
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected June 10, 2022 · Quality of Life and Care
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Potential for harm · D May 11, 2022
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected June 10, 2022 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 30, 2025 | Payment Denial | 2 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145413 · certified since November 1, 1980. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.