DANVILLE, IL — Goldwater Care Danville, a 90-bed skilled nursing facility on Warrington Avenue, has been fined $25,000 by the Illinois Department of Public Health after investigators determined that a staff failure during a medical emergency led to a resident's death in late 2024, according to the News-Gazette. The facility is also facing a $300,000 wrongful death lawsuit filed on behalf of the deceased resident's estate.
What Happened
The incident occurred on September 19, 2024, when resident Marion Ballard experienced a choking episode while eating lunch, according to WCIA. Ballard began aspirating on secretions and went into respiratory distress during the meal.
According to state investigators, Goldwater Care staff failed to provide timely emergency airway management and suctioning during the crisis. As reported by WCIA, staff members were unable to promptly locate suctioning equipment and did not contact paramedics or emergency services. A nurse practitioner eventually retrieved the necessary equipment and cleared phlegm from Ballard's airway, but his condition never stabilized. Ballard died later that evening, according to court filings cited by WCIA.
The Illinois Department of Public Health classified the incident as an "AA" violation — the most severe category in the state's regulatory framework — defined as a condition or occurrence that directly caused a resident's death, according to the News-Gazette. The agency noted that the failure "affected one of three residents reviewed for emergency airway management and has the potential to affect all 77 residents residing in the facility," as reported by the News-Gazette. The investigation was among 243 complaints the agency reviewed during the first quarter of 2025.
Wrongful Death Lawsuit
In April 2025, Dudley & Lake LLC, a Chicago law firm, filed a wrongful death lawsuit on behalf of Ballard's estate, according to WCIA. The suit names three entities — Goldwater Care Danville LLC, 620 Warrington Ave LLC, and Goldwater Care Management LLC — and seeks damages exceeding $50,000 on each of six counts, totaling more than $300,000, as reported by WCIA. A jury trial has been requested.
The News-Gazette reported that messages sent to Goldwater Care were not returned.
CMS Inspection History
Federal inspection data paints a troubling picture of Goldwater Care Danville that extends well beyond this single incident. The facility holds the lowest possible overall rating from the Centers for Medicare & Medicaid Services: one star out of five. Its health inspection rating is also one star, its quality measures rating is one star, and its staffing rating is two stars out of five.
Across 28 inspections documented in the CMS database, surveyors have recorded 110 total deficiencies — an average of nearly four deficiencies per inspection. The facility's most recent inspection, conducted on November 26, 2025, cited the home for failing to protect residents from wrongful use of their belongings or money.
An inspection from October 2, 2025, revealed several serious concerns. Surveyors cited the facility at a "J" severity level — indicating immediate jeopardy to resident health or safety — for failing to provide appropriate pressure ulcer care and prevent new ulcers from developing. Federal severity levels range from A (isolated, no harm) to L (widespread, immediate jeopardy), making a J-level citation among the most serious a facility can receive.
That same October inspection also cited Goldwater Care for failing to maintain adequate nursing staff to meet residents' needs, for medication error rates meeting or exceeding 5 percent, and for deficiencies in its infection prevention and control program. The staffing citation is particularly significant given that the choking death stemmed from staff being unable to locate emergency equipment and failing to call for outside help during a life-threatening event.
The pattern revealed in CMS data suggests systemic operational challenges at Goldwater Care rather than an isolated lapse. A one-star overall rating places the facility among the lowest-performing nursing homes in the country, and the combination of staffing shortfalls, quality-of-care failures, and the fatal emergency-response breakdown indicates persistent concerns about resident safety.
Ownership & Operations
Goldwater Care Danville is operated as a for-profit limited liability company, according to CMS records. The wrongful death lawsuit's naming of three separate corporate entities — Goldwater Care Danville LLC, 620 Warrington Ave LLC, and Goldwater Care Management LLC — reflects a corporate structure in which property ownership and facility management may be divided among related entities, a common arrangement in the for-profit nursing home industry.
Federal regulations require skilled nursing facilities to maintain sufficient trained staff to respond to medical emergencies, including having protocols and equipment readily accessible for airway management. Facilities receiving Medicare and Medicaid funding must comply with these standards as a condition of participation in those programs.
Resources for Families
Families with concerns about care at an Illinois nursing home can contact the Illinois Long-Term Care Ombudsman at 1-800-252-8966. The ombudsman program advocates for residents of nursing homes and other long-term care facilities, investigates complaints, and can help families understand their rights.
The national Elder Care Locator hotline, 1-800-677-1116, connects callers with local services and resources for older adults. Additional information about nursing home residents' rights is available through the National Long-Term Care Ombudsman Resource Center at [ltcombudsman.org](https://ltcombudsman.org).
Anyone can file a complaint against a licensed health care facility in Illinois through the Illinois Department of Public Health. Complaints may be submitted by residents, family members, or any member of the public who has concerns about conditions at a facility.