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Goldwater Care Peoria Heights

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5533 North Galena Road, Peoria Heights, IL 61614 (opens Google Maps) · Peoria County · (309) 682-5428· 94 certified beds · avg 57 residents/day · certified since Feb 2, 1972 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

SFF Candidate

What Special Focus status means →

Part of chain: GOLDWATER CARE (11 facilities, chain avg rating 1.5★)

1/5
Health inspection rating (on-site)
inspected Oct 1, 2024
14
Serious findings on record
most recent Jun 17, 2026
$527,947
Fines, last 3 years
2.44
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

New to these records? How to read an inspection report →

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →

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 quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy) — showing 10 of 14

▲ Immediate jeopardy, widespread · Feb 13, 2026 · F-0835 · triggered by a complaint

The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.

Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.

Severity (L): Immediate jeopardy to resident health or safety was cited. The scope was widespread: a systemic or pervasive problem. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 16, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Feb 13, 2026 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 16, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Feb 13, 2026 · F-0693 · triggered by a complaint

The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.

Why it matters: Unnecessary or poorly managed feeding tubes can cause serious complications like lung infections and take away the ability to eat normally.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 16, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Feb 27, 2024 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: May 3, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Dec 21, 2023 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 13, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Dec 21, 2023 · 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 (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 22, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Jun 17, 2026 · F-0578 · triggered by a complaint

The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.

Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: May 12, 2026 (Past Non-Compliance)

▲ Actual harm, isolated · Jun 17, 2026 · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jun 19, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · May 27, 2026 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jun 10, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Feb 13, 2026 · F-0550 · triggered by a complaint

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.

Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Apr 10, 2026 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 107 inspection findings. Open the full record below to read every finding.

  1. G · Actual harm, isolated

    The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint F-0578

  2. G · Actual harm, isolated

    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 F-0689

  3. D · Potential for more than minimal harm, isolated

    The facility required residents to give up Medicare or Medicaid benefits or pay privately as a condition of moving in, or failed to tell residents which types of care it does not provide. Both practices are against the rules. · from a complaint F-0620

View all 107 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
Jun 17, 2026▲ G · Actual harm, isolatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint · F-0578
Jun 17, 2026▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jun 17, 2026D · Potential for more than minimal harm, isolatedThe facility required residents to give up Medicare or Medicaid benefits or pay privately as a condition of moving in, or failed to tell residents which types of care it does not provide. Both practices are against the rules. · from a complaint · F-0620
May 27, 2026▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Apr 29, 2026E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Apr 15, 2026D · Potential for more than minimal harm, isolatedThe 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 · F-0600
Feb 28, 2026D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Feb 13, 2026▲ L · Immediate jeopardy, widespreadThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint · F-0835
Feb 13, 2026▲ J · Immediate jeopardy, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Feb 13, 2026▲ J · Immediate jeopardy, isolatedThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint · F-0693
Feb 13, 2026▲ G · Actual harm, isolatedThe 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. · from a complaint · F-0550
Feb 13, 2026▲ G · Actual harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Feb 13, 2026▲ G · Actual harm, isolatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697
Feb 13, 2026F · Potential for more than minimal harm, widespreadThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint · F-0679
Feb 13, 2026F · Potential for more than minimal harm, widespreadThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Feb 13, 2026F · Potential for more than minimal harm, widespreadThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint · F-0730
Feb 13, 2026F · Potential for more than minimal harm, widespreadThe 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. · from a complaint · F-0868
Feb 13, 2026F · Potential for more than minimal harm, widespreadThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint · F-0944
Feb 13, 2026E · Potential for more than minimal harm, patternThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677
Feb 13, 2026E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Feb 13, 2026D · Potential for more than minimal harm, isolatedThe facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. · from a complaint · F-0569
Feb 13, 2026D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Feb 13, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692
Feb 13, 2026D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760
Feb 13, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint · F-0773
Feb 13, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide or obtain x-rays and other imaging tests when ordered, or did not promptly tell the ordering doctor the results. · from a complaint · F-0777
Dec 7, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0607
Dec 7, 2025D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
Aug 6, 2025F · Potential for more than minimal harm, widespreadThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · from a complaint · F-0565
Aug 6, 2025D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Dec 7, 2024E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Oct 1, 2024F · Potential for more than minimal harm, widespreadThe 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. · F-0868
Oct 1, 2024F · Potential for more than minimal harm, widespreadThe 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. · F-0880
Oct 1, 2024F · Potential for more than minimal harm, widespreadThe 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. · F-0881
Oct 1, 2024E · Potential for more than minimal harm, patternThe 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. · F-0623
Oct 1, 2024D · Potential for more than minimal harm, isolatedThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · F-0645
Jul 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
May 18, 2024E · Potential for more than minimal harm, patternThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692
May 18, 2024D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0550
May 18, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
May 18, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
May 18, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint · F-0825
Apr 24, 2024E · Potential for more than minimal harm, patternThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759
Mar 21, 2024▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Mar 21, 2024F · Potential for more than minimal harm, widespreadThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Mar 21, 2024F · Potential for more than minimal harm, widespreadThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint · F-0838
Mar 21, 2024E · Potential for more than minimal harm, patternThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint · F-0690
Feb 27, 2024▲ J · Immediate jeopardy, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760
Feb 27, 2024▲ G · Actual harm, isolatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580
Feb 27, 2024F · Potential for more than minimal harm, widespreadThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint · F-0756
Feb 27, 2024E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Feb 27, 2024D · Potential for more than minimal harm, isolatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759
Jan 6, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0600
Jan 6, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint · F-0690
Dec 21, 2023▲ J · Immediate jeopardy, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Dec 21, 2023▲ J · Immediate jeopardy, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Dec 21, 2023F · Potential for more than minimal harm, widespreadThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Dec 21, 2023F · Potential for more than minimal harm, widespreadThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint · F-0835
Dec 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint · F-0558
Dec 21, 2023D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0657
Dec 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677
Nov 30, 2023F · Potential for more than minimal harm, widespreadThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint · F-0727
Nov 30, 2023F · Potential for more than minimal harm, widespreadThe 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 · F-0880
Nov 30, 2023E · Potential for more than minimal harm, patternThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint · F-0761
Nov 30, 2023D · Potential for more than minimal harm, isolatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759
Oct 31, 2023F · Potential for more than minimal harm, widespreadThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Oct 31, 2023F · Potential for more than minimal harm, widespreadThe 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 · F-0880
Oct 31, 2023D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0657
Oct 31, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · F-0679
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. · F-0680
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · F-0727
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · F-0806
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · F-0835
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · F-0837
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe 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. · F-0868
Jul 24, 2023F · Potential for more than minimal harm, widespreadThe 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. · F-0880
Jul 24, 2023E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
Jul 24, 2023E · Potential for more than minimal harm, patternThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656
Jul 24, 2023E · Potential for more than minimal harm, patternThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · F-0636
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · F-0637
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. · F-0638
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · F-0655
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0657
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · F-0690
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0695
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0758
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · F-0760
Jul 24, 2023D · Potential for more than minimal harm, isolatedThe facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. · F-0847
Jul 24, 2023C · Potential for minimal harm, widespreadThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732
Aug 12, 2022E · Potential for more than minimal harm, patternThe facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · F-0553
Aug 12, 2022E · Potential for more than minimal harm, patternThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · F-0557
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · F-0677
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · F-0791
Aug 12, 2022D · Potential for more than minimal harm, isolatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0921

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (28 → 5).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2022
All citations: 10
Serious citations (G–L): 0
2023
All citations: 43
Serious citations (G–L): 2
2024
All citations: 24
Serious citations (G–L): 3
2025
All citations: 4
Serious citations (G–L): 0
2026
All citations: 26
Serious citations (G–L): 9

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
2022100E
2023432J ▲
2024243J ▲
202540F
2026269L ▲

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)

How to file a complaint about care →

2 fines totaling $527,947, plus 2 Medicare payment denial periods.

Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.

DateTypeAmount / length
Feb 13, 2026Fine$346,525
Feb 13, 2026Payment Denial34 days from Mar 13, 2026
Nov 30, 2023Fine$181,422
Nov 30, 2023Payment Denial111 days from Jan 20, 2024

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityIllinois averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 2.44
Illinois average: 2.99
U.S. average: 3.95
Registered Nurse hours
This facility: 0.13
Illinois average: 0.63
U.S. average: 0.69
Weekend total nurse staffing
This facility: 2.26
Illinois average: 2.67
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityIllinois avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)2.442.993.95bottom 32% in Illinois; bottom 3% in the U.S.
Registered Nurse hours0.130.630.69bottom 1% in Illinois; bottom 1% in the U.S.
Weekend total nurse staffing2.262.673.50bottom 39% in Illinois; bottom 4% in the U.S.
Weekend RN hours (not acuity-adjusted)0.230.560.48bottom 12% in Illinois; bottom 18% in the U.S.
Total nursing staff turnover (%)54.244.545.8bottom 24% in Illinois; bottom 27% in the U.S.
RN turnover (%)—41.842.9—

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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 3.76, RN 0.21, weekend 3.48.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.76 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 1/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Goldwater Care Peoria Heights. CMS inspection and staffing records do not tell us what this home will charge you.

Calculate a stay from a quote you receive

Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.

Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.

Before you compare prices

  • Request the room type, effective date and itemized daily rate in writing.
  • Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
  • Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.

Understand who pays for care · How we handle price evidence · Report an incorrect price

Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

For profit - Corporation

Owner / managerTypeRoleStakeSince
Ahearn, MichaelIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Ahearn, MichaelIndividualADP of the SNFNOT APPLICABLE12/01/2024
Berkowitz, DavidIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE05/29/2025
Berkowitz, DavidIndividualTrustee of the SNFNOT APPLICABLE12/01/2024
Curis Services LLCOrganizationADP of the SNFNOT APPLICABLE12/01/2024
Goldwater Care Management LLCOrganizationOperational/Managerial ControlNOT APPLICABLE12/01/2024
Goldwater Care Management LLCOrganizationADP of the SNFNOT APPLICABLE03/19/2025
Meystel, YosefIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE03/19/2025
Petersen SNF Holdings LLCOrganizationADP of the SNFNOT APPLICABLE03/19/2025
Spector, JenniferIndividualCorporate DirectorNOT APPLICABLE12/01/2024
Spector, JenniferIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Spector, JenniferIndividualADP of the SNFNOT APPLICABLE12/01/2024
Stachowiak, MelissaIndividualManaging Control - Governing BodyNOT APPLICABLE12/01/2024
Stachowiak, MelissaIndividualADP of the SNFNOT APPLICABLE12/01/2024
Stewart, JasonIndividualManaging Control - Governing BodyNOT APPLICABLE12/01/2024
Stewart, JasonIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Stewart, JasonIndividualADP of the SNFNOT APPLICABLE12/01/2024
Turofsky, StevenIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Turofsky, StevenIndividualADP of the SNFNOT APPLICABLE12/01/2024
Tversky, AaronIndividualManaging Control - Governing BodyNOT APPLICABLE12/01/2024

Showing 20 of 24 parties CMS has on file for this facility; 4 are not displayed. The full list is in the CMS Ownership dataset.

Other facilities in the same chain

CMS lists this facility under the chain Goldwater Care — 11 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.

Listed by state, then facility name — not a ranking. Showing 8 of the 10 others, continuing from this facility's own place in that list.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

  • "What were the findings behind this administration citation, and what has leadership changed since?"
  • "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
  • "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
  • "What systems do you use to prevent medication errors, and what happens when one occurs?"
  • "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
  • "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
  • "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
  • "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"

Also worth asking anywhere

  • "Your weekend nurse staffing is reported below the Illinois midpoint — how does the weekend schedule differ from a weekday?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 54% total nursing staff turnover here — who on the care team has been with you longest?"
  • "The ownership record on file lists 24 owning or managing parties — who makes the decisions about staffing levels?"
  • "CMS lists this facility under its Special Focus program — what is being done differently, and by when?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 22 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Arcadia Care Peoria Heights0.3 miPeoria Heights, IL—/5abuseSFF
Lutheran Hillside Village1.1 miPeoria, IL★★★★★4/5
Accolade Healthcare of Peoria1.4 miPeoria, IL★★★☆☆3/5
Apostolic Christian Skylines2.0 miPeoria, IL★★★★★5/5
Loft Rehab of Peoria, the2.7 miPeoria, IL★☆☆☆☆1/5abuse
Loft Rehab of East Peoria, the4.3 miEast Peoria, IL★★★★★5/5
Sharon Health Care Pines4.5 miPeoria, IL★☆☆☆☆1/5abuse
Sharon Health Care Elms4.5 miPeoria, IL★☆☆☆☆2/5
Sharon Health Care Willows4.5 miPeoria, IL★☆☆☆☆2/5abuse
Fondulac Rehabilitation and Health Care Center5.6 miEast Peoria, IL★☆☆☆☆1/5abuseSFF
Manor Court of Peoria6.0 miPeoria, IL★★★☆☆3/5
Washington Senior Living8.1 miWashington, IL★☆☆☆☆2/5

Compare this facility with the 3 closest →

All facilities in Peoria Heights →

Facility data as of CMS processing date 2026-08-01. CCN 145239.

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