Goldwater Care Toluca
101 East Via Ghiglieri, Toluca, IL 61369 · Marshall County · 104 certified beds · avg 60 residents/day · certified since Nov 1, 1980
Abuse citation flag (CMS)
Part of chain: GOLDWATER CARE (11 facilities, chain avg rating 1.5★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 30, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 31, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 27, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 30, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 30, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 30, 2025 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint |
| Dec 30, 2025 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Dec 30, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Sep 26, 2025 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Sep 26, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 26, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Sep 26, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Sep 26, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 26, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 26, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 26, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 26, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Dec 27, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 10, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint |
| Dec 10, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| May 2, 2024 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| May 2, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 2, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 2, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| May 2, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 2, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| May 12, 2023 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| May 12, 2023 | E · Potential for harm, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| May 12, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 12, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| May 12, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| May 12, 2023 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | E |
| 2024 | 9 | 1 | G ▲ |
| 2025 | 13 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
0 fines totaling $0, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Dec 30, 2025 | Payment Denial | 2 days from Jan 22, 2026 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.27 | 2.99 | 3.95 | bottom 21% in Illinois; bottom 2% in the U.S. |
| Registered Nurse hours | 0.51 | 0.63 | 0.69 | top 48% in Illinois; bottom 39% in the U.S. |
| Weekend total nurse staffing | 2.09 | 2.67 | 3.50 | bottom 26% in Illinois; bottom 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.53 | 0.56 | 0.48 | top 40% in Illinois; top 29% in the U.S. |
| Total nursing staff turnover (%) | 43.4 | 44.5 | 45.8 | top 50% in Illinois; top 46% in the U.S. |
| RN turnover (%) | 53.8 | 41.8 | 42.9 | bottom 30% in Illinois; bottom 30% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.16, RN 0.71, weekend 2.90. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 101 E. via Ghiglieri, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Ahearn, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Ahearn, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Berkowitz, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Curis Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| David a Berkowitz Delta Trust | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Glynn, Elizabeth | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2024 |
| Glynn, Elizabeth | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Glynn, Elizabeth | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Goldwater Care Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Goldwater Care Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Jay, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Jay, John | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Katzenstein, Meir | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2024 |
| Katzenstein, Meir | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Katzenstein, Meir | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Meystel, Yosef | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Spector, Jennifer | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2024 |
| Spector, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2024 |
| Spector, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "How does your quality committee work, and can you share an example of a problem it identified and fixed?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Henry Rehab and Nursing | 13.9 mi | Henry, IL | ★★★★★ | 5/5 | |
| Lacon Rehab and Nursing | 14.5 mi | Lacon, IL | ★★☆☆☆ | 1/5 | |
| Apostolic Christian Home | 15.5 mi | Roanoke, IL | ★★★★★ | 4/5 | |
| Flanagan Rehabilitation and Health Care Center | 15.5 mi | Flanagan, IL | ★★☆☆☆ | 2/5 | |
| Parker Nursing & Rehab Center | 17.5 mi | Streator, IL | ★☆☆☆☆ | 2/5 | |
| Arc at Streator | 18.4 mi | Streator, IL | ★★★☆☆ | 3/5 | |
| Snyder Village | 18.9 mi | Metamora, IL | ★★★★★ | 4/5 | |
| El Paso Rehabilitation and Health Care Center | 19.9 mi | El Paso, IL | —/5 | abuseSFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 145413.