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Nursing HomeMedicaid Investigative

Goldwater Care Toluca

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

101 East Via Ghiglieri, Toluca, IL 61369104 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.1/5

based on 31 Google reviews

5
4
3
2
1

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7/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • High staff turnover (56%)
  • High RN turnover (57%)

Bottom 25% in IL · Below recommended RN staffing · Worst in GOLDWATER CARE chain · No penalties on record · Abuse citation

Source: Medicare data

What this means for your family

While the facility has an active and well-regarded activity department, the recurring reports of delayed call light responses and dietary errors are significant red flags. We strongly recommend that you visit during off-hours or weekends to observe staffing levels firsthand and verify how they manage specific medical dietary needs before committing.

Google Reviews

Google Reviews

31 reviews on Google
Goldwater Care Toluca (formerly Aperion Care) receives highly polarized feedback, with some families praising the compassionate staff and engaging activity department, while others report severe concerns regarding understaffing and neglect. Critical reviews frequently cite long response times for call lights, failure to adhere to prescribed dietary restrictions, and poor administrative responsiveness to complaints. Potential families should be aware of the significant disparity between positive testimonials and reports of substandard care.

Quality Themes

Tap a score for details
Food2.0Staff5.0Clean3.0Activities9.0Meds2.0MemoryN/AComms2.0ValueN/A

Strengths

  • Engaging activity department
  • Welcoming and compassionate frontline staff
  • Pleasant outdoor visitor areas

Concerns

  • Chronic understaffing leading to long call light response times (mentioned by 6 reviewers)
  • Failure to accommodate medically necessary dietary restrictions (mentioned by 4 reviewers)
  • Poor administrative responsiveness and ineffective corporate hotline (mentioned by 4 reviewers)
  • Sanitation and cleanliness issues (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'16(1)'18(3)'20(3)'22(9)'25(1)'26(1)

Distribution · 33 analyzed

5
14
4
2
3
1
2
0
1
16

How They Respond to Reviews

33%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1Given that staffing levels are a top priority for your residents, what specific protocols are in place to ensure call lights are answered promptly during peak hours?
  • 2I noticed that dietary needs are a major focus for families; how does your kitchen team coordinate with clinical staff to ensure residents with specific medical dietary restrictions receive the correct meals every time?
  • 3With cleanliness being an area you are working to improve, could you walk me through your current daily sanitation schedule for resident rooms and common areas?
  • 4I see that your activity department is highly regarded; what are some of the most popular social programs or outdoor activities that residents are currently enjoying?
  • 5When a family has a concern or a question, what is the most effective way to communicate with administration to ensure a timely and helpful response?
  • 6How does your nursing team manage medication administration and oversight to ensure accuracy for residents with complex health needs?

Personalized based on this facility's data


Key Review Excerpts

The Activity department under Sue and Joey really rocks. From holiday activities to cosmic bowling they keep the residents engaged.

Family member · 2022★★★★★

They are extremely under staffed so that means if your loved one is having a medical emergency it could 30 minutes for a nurse to get to their room after pressing the call light several times.

Family member · 2022☆☆☆☆

The staff was more than welcoming when we arrived even though the nurses were busy with medication and serving dinner. The director came out and introduced herself which I thought was nice.

Family member · 2022★★★★★
Source: 31 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.65hrs
86%
Registered nurses for medical care
Total Nursing
3.10hrs
76%
All nurses + aides combined
Staff Turnover
52%
Lower is better (< 30% = good)
RN Turnover
67%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
3/ 5
Better Than Avg

9

measures

Worse Than Avg

6

measures

Mixed Results

1

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility73.4%
Worse than Avg
Here
73.4%
US
12.1%
IL
52.5%
Marshall
6.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility38.7%
Worse than Avg
Here
38.7%
US
15.5%
IL
21.8%
Marshall
17.1%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility36.7%
Worse than Avg
Here
36.7%
US
19.5%
IL
18.3%
Marshall
23.7%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility30.1%
Worse than Avg
Here
30.1%
US
19.4%
IL
21.1%
Marshall
20.8%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility4.9%
Better than Avg
Here
4.9%
US
14.4%
IL
14.2%
Marshall
14.7%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.0%
Better than Avg
Here
8.0%
US
15.3%
IL
15.9%
Marshall
16.6%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility80.0%
Mixed vs Avgs
Here
80.0%
US
81.8%
IL
69.0%
Marshall
84.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
IL
2.4%
Marshall
2.0%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

10deficiencies
1penalties
Near state avg (12.0)
7 complaint-triggered

Goldwater Care Toluca has concerning patterns with families filing complaints leading to 7 deficiencies, including recent issues with abuse protection and dietary services in late 2024/2025. The facility struggles most with resident safety, medication management, and infection control, with safety hazards appearing across multiple surveys from 2022-2025. While all violations show correction dates, the recurring nature of safety and care quality issues across three years suggests ongoing management challenges that warrant careful consideration.

Dec 30, 2025Complaint
4
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0801Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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.

0803Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Dec 27, 2024Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Dec 10, 2024Complaint
2
0882Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

May 2, 2024Routine
11
0868Potential for harm · WidespreadCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0291Potential for harm · WidespreadCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0321Potential for harm · PatternCorrected

Smoke Deficiencies

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

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

May 12, 2023Routine
8
0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

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

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0623Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0625Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0577Minimal · WidespreadCorrected

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

May 11, 2022Routine
12
0868Potential for harm · WidespreadCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0558Potential for harm · PatternCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

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

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0374Potential for harm · PatternCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0732Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Federal Penalties

Payment Denial

Dec 30, 2025

2-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Goldwater Care Toluca

Organization Type

for profit

Chain Affiliation

Chain Name

Goldwater Care

Chain Size

11 facilities nationwide

Chain avg rating: 1.4/5 · Rank 10 of 11 (Worst)

Ownership & Management

Owners

Berkowitz, David

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Meystel, Yosef

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Glynn, ElizabethManaging Control - Governing BodyStachowiak, MelissaManaging Control - Governing BodyKatzenstein, MeirOfficer / DirectorSpector, JenniferOfficer / DirectorTversky, AaronOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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