Goldwater Care Toluca

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

285 of 664 Illinois homes (43%) got a citation at the actual harm level in 2026.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS has cited this home for F0689 4 times since 2023.

See this home on CMS Care Compare

CMS fine of $15,185 on August 18, 2026.

See this home on CMS Care Compare

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

CMS stopped payment for new admissions from January 22, 2026, for 2 days.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.

• Citation F0600. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on December 31, 2025.

• Citation F0801. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 31, 2025.

• Citation F0803. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 24, 2026.

• Citation F0607. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on December 31, 2025.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation F0868. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  CMS lists it as corrected on September 29, 2025.

  CMS has cited this home for F0868 2 times since 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 29, 2025.

  CMS has cited this home for F0880 3 times since 2024.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on September 29, 2025.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on September 29, 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on September 29, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on September 29, 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on September 29, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on September 29, 2025.

• Citation F0881. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on September 29, 2025.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation K0291. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on October 29, 2025.

  CMS has cited this home for K0291 2 times since 2024.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on October 1, 2025.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on October 29, 2025.

  CMS has cited this home for K0923 2 times since 2024.

See this home on CMS Care Compare

• Staffing

  Total nurse staffing reported to CMS went from 3.5 to 3.1 hours per resident per day.

• Changed ownership in the last 12 months

  CMS no longer shows a change of ownership in the past 12 months.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 30, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0882. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  CMS lists it as corrected on December 14, 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on December 12, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 4 of 5.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Changed ownership in the last 12 months

  CMS records show a change of ownership in the past 12 months.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

• Name

  CMS lists a new legal business name for this home.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5.

• Name

  CMS lists a new name for this home. It was APERION CARE TOLUCA.

CMS lists this as a standard inspection.

• Citation F0868. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  CMS lists it as corrected on May 8, 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 8, 2024.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on May 8, 2024.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on May 8, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 8, 2024.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 8, 2024.

  CMS has cited this home for F0758 2 times since 2023.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on May 23, 2024.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on May 16, 2024.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on May 9, 2024.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on May 2, 2024.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on May 3, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.3 to 3.0 hours per resident per day.

CMS lists this as a standard inspection.

• Citation F0623. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on May 26, 2023.

• Citation F0625. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 26, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 26, 2023.

• Citation F0699. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on May 26, 2023.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 26, 2023.

• Citation F0577. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on May 26, 2023.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on May 26, 2023.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on May 26, 2023.

See this home on CMS Care Compare