Map showing the location of GOLDWATER CARE GIBSON CITY in GIBSON CITY, Illinois
620 EAST FIRST STREET, GIBSON CITY, IL, 60936

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating

Where it ranks

  • IllinoisLowest tier among peers665 rated homes · average 2.5★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.7 vs IL avg
  • StaffingCan add or remove a star1★−1.1 vs IL avg
  • Quality measuresCan add or remove a star2★−0.9 vs IL avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersIL avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersIL avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 17% of peersIL avg2.9★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.41hrsAbove 53% of peersIL avg3.49Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.55hrsAbove only 40% of peersIL avg0.73Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better51%Above only 33% of peersIL avg46%RN turnover40%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$84,595Above only 36% of peersIL avg$95,677Fines · denials5 · 3
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
74citations
19inspection dates
6actual harm (G–I)
1immediate jeopardy (J–L)
Dec 23, 2025most recent

Citations by monthFeb 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 23, 20254 citationsCycle 1worst E · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 24, 2025
  2. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Dec 24, 2025
  3. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Dec 24, 2025
  4. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareE · patternCorrected Dec 24, 2025
Sep 14, 20251 citationCycle 1worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Sep 15, 2025
May 8, 20255 citationsCycle 1worst G · actual harm
  1. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 1, 2025
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 1, 2025
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected May 29, 2025
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jul 1, 2025
  5. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 3, 2025
Mar 28, 20252 citationsCycle 1worst E · no actual harmpayment denial
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Mar 31, 2025
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Mar 31, 2025
Oct 23, 20241 citationCycle 2worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Oct 24, 2024
Oct 1, 20241 citationCycle 2worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Oct 2, 2024
Sep 26, 20242 citationsCycle 2worst J · immediate jeopardy$59,827, payment denial
  1. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Sep 27, 2024
  2. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceJ · isolatedCorrected Sep 27, 2024
Jul 9, 20243 citationsCycle 2worst E · no actual harm
  1. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jul 13, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jul 13, 2024
  3. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 13, 2024
Jul 3, 20246 citationsCycle 2worst G · actual harm
  1. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Jul 6, 2024
  2. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationF · widespreadCorrected Jul 6, 2024
  3. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jul 6, 2024
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Jul 6, 2024
  5. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Jul 6, 2024
  6. F946Provide training in compliance and ethics.AdministrationF · widespreadCorrected Jul 6, 2024
Apr 24, 20241 citationCycle 2worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 26, 2024
Mar 19, 20243 citationsCycle 2worst D · no actual harm
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 28, 2024
  2. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Mar 28, 2024
  3. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Mar 28, 2024
Feb 6, 202412 citationsCycle 2worst E · no actual harm
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Feb 20, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 20, 2024
  3. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Feb 20, 2024
  4. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Feb 20, 2024
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Feb 20, 2024
  6. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Feb 20, 2024
  7. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Feb 20, 2024
  8. F688Provide 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.Quality of Life and CareD · isolatedCorrected Feb 20, 2024
  9. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Feb 20, 2024
  10. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Feb 20, 2024
  11. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Feb 20, 2024
  12. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Feb 20, 2024
Oct 18, 20233 citationsCycle 3worst G · actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Nov 16, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 17, 2023
  3. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Nov 16, 2023
Sep 1, 20231 citationCycle 3worst D · no actual harm
  1. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Sep 4, 2023
Aug 16, 20232 citationsCycle 3worst G · actual harm$2,447, $2,117
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Nov 16, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 17, 2023
Jul 24, 20231 citationCycle 3worst E · no actual harm$15,971, payment denial, $4,233
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Aug 15, 2023
Jun 13, 20231 citationCycle 3worst D · no actual harm
  1. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 28, 2023
Feb 16, 202324 citationsCycle 3worst F · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Mar 15, 2023
  2. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Mar 15, 2023
  3. F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Quality of Life and CareE · patternCorrected Mar 15, 2023
  4. F758Implement 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.Pharmacy ServiceE · patternCorrected Mar 15, 2023
  5. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Mar 15, 2023
  6. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Mar 15, 2023
  7. F803Ensure 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.Nutrition and DietaryE · patternCorrected Mar 15, 2023
  8. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 15, 2023
  9. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 15, 2023
  10. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Mar 15, 2023
  11. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 15, 2023
  12. F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected Mar 15, 2023
  13. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Mar 15, 2023
  14. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlE · patternCorrected Mar 15, 2023
  15. F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.EnvironmentalE · patternCorrected Mar 15, 2023
  16. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Mar 15, 2023
  17. F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsD · isolatedCorrected Mar 15, 2023
  18. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Mar 15, 2023
  19. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 15, 2023
  20. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 15, 2023
  21. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Mar 15, 2023
  22. F888Ensure staff are vaccinated for COVID-19Infection ControlF · widespreadCorrected Mar 15, 2023
  23. F885Report COVID19 data to residents and families.Infection ControlF · widespreadCorrected Mar 15, 2023
  24. F886Perform COVID19 testing on residents and staff.Infection ControlF · widespreadCorrected Mar 15, 2023
Feb 1, 20231 citationCycle 3worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 22, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.41hrsAbove 53% of peers−0.08 vs IL avg
  • Registered nursesRN hours only0.55hrsAbove only 40% of peers−0.18 vs IL avg
  • Licensed practical nursesLPN hours0.50hrs
  • Nurse aidesCNA hours2.36hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.28hrs
  • Illinois average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better51%Above only 33% of peersIL avg 46%
  • RN turnoverRegistered nurses only40%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy60 certified beds · ~53 residents a day89%Above 82% of peersIL avg 74%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $84,595In fines
  • 5Fines
  • 3Payment denials
  • $95,677IL avg in fines
Above only 36% of peersFewer fines than 36% of rated homes in Illinois

Actions on record

  1. Mar 28, 2025Denial of payment for new admissionsfrom May 31, 2025
  2. Sep 26, 2024Civil money penalty$59,827
  3. Sep 26, 2024Denial of payment for new admissionsfrom Oct 22, 2024
  4. Aug 14, 2023Civil money penalty$2,447
  5. Aug 7, 2023Civil money penalty$2,117
  6. Jul 24, 2023Civil money penalty$15,971
  7. Jul 24, 2023Denial of payment for new admissionsfrom Sep 12, 2023
  8. Jul 17, 2023Civil money penalty$4,233

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Goldwater Care11 facilities in the chain1.6★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • David a Berkowitz Revoc Tr David Berkowitz Ttee
  • Yosef Meystel Declaration of Tr of Yosef Meystel Ttee
  • Meir Katzenstein
  • Aaron Tversky
Indirect owners (5%+)
  • David Berkowitz
  • Yosef Meystel
Operational or managerial control
  • Jennifer Spector
Corporate directors
  • Jennifer Spector
Managing employees
  • Linda Bane

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 145911 · 620 EAST FIRST STREET, GIBSON CITY, IL, 60936.
  • Percentiles compare this facility with every rated nursing home in Illinois and Ford County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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