Goldwater Pontiac Nursing Home

Name: Goldwater Pontiac Nursing Home
Address: 1225 SOUTH EWING DRIVE, Pontiac, IL, 61764, US
Telephone: 8158445121

1225 South Ewing Drive, Pontiac, IL 61764 · Livingston County · 90 certified beds · avg 85 residents/day · certified since Aug 1, 1997

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

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

2.51

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5

⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.

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 self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · May 16, 2024 · F-0740

The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.

Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 21, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (33)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 29, 2026	D · Potential for harm, one-off	The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint
Jun 29, 2026	D · Potential for harm, one-off	The 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
Jun 29, 2026	D · Potential for harm, one-off	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
Aug 20, 2025	D · Potential for harm, one-off	The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Aug 20, 2025	D · Potential for harm, one-off	The 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
Aug 20, 2025	D · Potential for harm, one-off	The 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. · from a complaint
Nov 25, 2024	E · Potential for harm, repeated	The 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
Nov 25, 2024	D · Potential for harm, one-off	The 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
Nov 25, 2024	D · Potential for harm, one-off	The 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
May 16, 2024	▲ G · Actual harm, one-off	The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
May 16, 2024	F · Potential for harm, facility-wide	The 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.
May 16, 2024	D · Potential for harm, one-off	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.
May 16, 2024	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
May 16, 2024	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 16, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 16, 2024	D · Potential for harm, one-off	The 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.
May 16, 2024	D · Potential for harm, one-off	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.
May 16, 2024	D · Potential for harm, one-off	The 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.
May 16, 2024	D · Potential for harm, one-off	The 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.
May 16, 2024	D · Potential for harm, one-off	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.
Sep 27, 2023	E · Potential for harm, repeated	The 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
Jul 28, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 28, 2023	F · Potential for harm, facility-wide	The 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.
Jul 28, 2023	F · Potential for harm, facility-wide	The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Jul 28, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jul 28, 2023	D · Potential for harm, one-off	The 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.
Jul 28, 2023	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jul 28, 2023	D · Potential for harm, one-off	The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Jul 28, 2023	D · Potential for harm, one-off	The 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.
Jul 28, 2023	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Aug 12, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 12, 2022	E · Potential for harm, repeated	The 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.
Aug 12, 2022	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 11).

Year	Citations	Serious (G–L)	Worst severity that year
2022	3	0	F
2023	10	0	F
2024	14	1	G ▲
2025	3	0	D
2026	3	0	D

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)

No fines or payment denials in the published 3-year window.

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

Measure	This facility	Illinois avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.51	2.99	3.95	bottom 37% in Illinois; bottom 4% in the U.S.
Registered Nurse hours	0.21	0.63	0.69	bottom 7% in Illinois; bottom 3% in the U.S.
Weekend total nurse staffing	2.26	2.67	3.50	bottom 39% in Illinois; bottom 4% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.16	0.56	0.48	bottom 5% in Illinois; bottom 7% in the U.S.
Total nursing staff turnover (%)	43.3	44.5	45.8	top 49% in Illinois; top 45% in the U.S.
RN turnover (%)	50.0	41.8	42.9	bottom 37% in Illinois; bottom 39% in the U.S.

Hours are per resident per day, 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 3.24, RN 0.27, weekend 2.91. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
David a Berkowitz Revoc Tr David Berkowitz Ttee	Organization	Direct Ownership Interest	NOT APPLICABLE	10/01/2022
1225 S Ewing Drive, LLC	Organization	ADP of the SNF	NOT APPLICABLE	03/28/2025
Berkowitz, David	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	04/23/2025
Curis Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	10/01/2022
Devault, Diana	Individual	Managing Control - Governing Body	NOT APPLICABLE	10/01/2022
Devault, Diana	Individual	Operational/Managerial Control	NOT APPLICABLE	10/01/2022
Devault, Diana	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2022
Goldwater Care Management LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	10/01/2022
Goldwater Care Management LLC	Organization	ADP of the SNF	NOT APPLICABLE	03/28/2025
Katzenstein, Meir	Individual	Corporate Officer	NOT APPLICABLE	10/01/2022
Katzenstein, Meir	Individual	Operational/Managerial Control	NOT APPLICABLE	10/01/2022
Katzenstein, Meir	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2022
Mays, Erin	Individual	Operational/Managerial Control	NOT APPLICABLE	10/01/2022
Mays, Erin	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2022
Meystel, Yosef	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	04/23/2025
Spector, Jennifer	Individual	Corporate Officer	NOT APPLICABLE	10/01/2022
Spector, Jennifer	Individual	Operational/Managerial Control	NOT APPLICABLE	10/01/2022
Spector, Jennifer	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2022
Stachowiak, Melissa	Individual	Managing Control - Governing Body	NOT APPLICABLE	10/01/2022
Stachowiak, Melissa	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2022

Questions to ask on your visit

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

"What mental health services do you provide on-site, and who delivers them?"
"How are residents' personal funds handled here, and what records can families review?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Accolade Healthcare of Pontiac	2.4 mi	Pontiac, IL	★★★☆☆	3/5
Evenglow Lodge	2.7 mi	Pontiac, IL	★★★★★	5/5
Fairview Haven	11.6 mi	Fairbury, IL	★★★★★	5/5
Flanagan Rehabilitation and Health Care Center	12.2 mi	Flanagan, IL	★★☆☆☆	2/5
Arc at Streator	19.0 mi	Streator, IL	★★★☆☆	3/5
El Paso Rehabilitation and Health Care Center	19.2 mi	El Paso, IL		—/5	abuseSFF
Arc at el Paso	19.6 mi	El Paso, IL	★★☆☆☆	2/5	abuse

Compare this facility with the 3 closest →

All facilities in Pontiac →

Facility data as of CMS processing date 2026-08-01. CCN 145930.

The Care File

Visit checklist — Goldwater Pontiac Nursing Home

1225 South Ewing Drive, Pontiac, IL 61764 · 8158445121

Health inspection rating 3/5 · CMS overall 2/5· Fines (3y): $0

Most serious findings on record:

▲ May 16, 2024 (F-0740, Actual harm, one-off): The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.

Questions for the administrator:

☐ "What mental health services do you provide on-site, and who delivers them?"
☐ "How are residents' personal funds handled here, and what records can families review?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 145930 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)