Goldwater Care Peoria Heights, Peoria Heights, Illinois

117
Citations from health inspectionsIllinois average: 38 a home: 16
Residents harmed or put in dangerIllinois average: 4.6 a home: $703,747
Fines from the federal governmentIllinois average: $111,013 a home: 1 out of 5
Overall rating in starsIllinois average: 2.5

The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files

21 inspection visits produced 117 citations. Residents were in immediate danger in six findings. Residents were found hurt in 10 cases. Federal fines came to $703,747 (three fines). Three times, Medicare stopped paying for new admissions.

A candidate for Special Focus. For its list of nursing homes with past poor inspection results, CMS has named this home a candidate.

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Quick Look at the Record

The home's overall star rating: 1 out of 5
Rating for health inspections: 1 out of 5
Rating for staffing: 1 out of 5
Rating for quality of care: 3 out of 5
Nurse time for each resident: 3.76 hours each dayThe Illinois average is 3.45 hours
Time from registered nurses: 0.21 hours each dayThe Illinois average is 0.72 hours
Nursing staff who left during one year: 54.2%against the Illinois average of 44.5%
Beds that are certified: 94
Ownership: Limited Liability company (for profit)
Chain: Goldwater Care, with 11 homes
Street address: 5533 North Galena Road, Peoria Heights, Illinois 61614
County: Peoria

Each inspection's citations

Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.

One citation dated July 13, 2026

F602 Protect Residents' Money and Belongings From Misuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

Three citations dated June 17, 2026

F689 Accident Hazards and Supervision: residents were harmed, one or a few residents, found on a complaint visit.
F620 Fair Admission Without Giving Up Benefits: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F578 The Right to Refuse Treatment: residents were harmed, one or a few residents, found on a complaint visit.

One citation dated May 27, 2026

F686 Pressure Ulcer (Bedsore) Care: residents were harmed, one or a few residents, found on a complaint visit.

20 citations dated April 29, 2026

F887 Coronavirus Vaccine Education, Offering, and Records: risk of harm, no one found hurt, widespread.
F881 Antibiotic Use Monitoring Program: risk of harm, no one found hurt, widespread.
F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, one or a few residents.
F727 Required Registered Nurse and Nursing Director: risk of harm, no one found hurt, widespread.
F699 Trauma Informed and Culturally Respectful Care: risk of harm, no one found hurt, one or a few residents.
F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents.
F686 Pressure Ulcer (Bedsore) Care: residents were harmed, one or a few residents.
F679 Activities That Meet Every Resident's Needs: risk of harm, no one found hurt, one or a few residents.
F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents.
F645 Screening for Mental Illness or Intellectual Disability: risk of harm, no one found hurt, one or a few residents.
F644 Coordinate Assessments With Mental Health Screening Program: risk of harm, no one found hurt, one or a few residents.
F628 Required Transfer Paperwork and Notices: risk of harm, no one found hurt, one or a few residents.
F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents.
F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents.
F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F582 Notice of Medicare and Medicaid Coverage and Costs: risk of harm, no one found hurt, a pattern, several residents.
F550 Dignity and Resident Rights: residents were harmed, one or a few residents.

One citation dated April 15, 2026

F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

One citation dated Feb. 28, 2026

F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

19 citations dated Feb. 13, 2026

F944 Staff Training on Quality Improvement Program: risk of harm, no one found hurt, widespread, found on a complaint visit.
F868 Quality Group Membership and Quarterly Meetings: risk of harm, no one found hurt, widespread, found on a complaint visit.
F835 Run the Facility Effectively: immediate danger to residents, widespread, found on a complaint visit.
F777 Order X Rays and Report Results Promptly: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F773 Order Laboratory Tests and Report Results Promptly: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F760 Significant Medication Errors: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F730 Review Nurse Aide Performance and Training: risk of harm, no one found hurt, widespread, found on a complaint visit.
F725 Enough Nursing Staff: risk of harm, no one found hurt, widespread, found on a complaint visit.
F697 Pain Management: residents were harmed, one or a few residents, found on a complaint visit.
F693 Feeding Tube Care: immediate danger to residents, one or a few residents, found on a complaint visit.
F692 Enough Food and Fluids: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F686 Pressure Ulcer (Bedsore) Care: immediate danger to residents, one or a few residents, found on a complaint visit.
F684 Quality of Care: residents were harmed, one or a few residents, found on a complaint visit.
F679 Activities That Meet Every Resident's Needs: risk of harm, no one found hurt, widespread, found on a complaint visit.
F677 Help With Daily Living: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F569 Return Resident Funds After Discharge or Death: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F550 Dignity and Resident Rights: residents were harmed, one or a few residents, found on a complaint visit.

Two citations dated Dec. 7, 2025

F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F607 Policies to Prevent Abuse, Neglect, and Theft: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

Two citations dated Aug. 6, 2025

F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F565 Right to Resident and Family Groups: risk of harm, no one found hurt, widespread, found on a complaint visit.

One citation dated Dec. 7, 2024

F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.

Five citations dated Oct. 1, 2024

F881 Antibiotic Use Monitoring Program: risk of harm, no one found hurt, widespread.
F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread.
F868 Quality Group Membership and Quarterly Meetings: risk of harm, no one found hurt, widespread.
F645 Screening for Mental Illness or Intellectual Disability: risk of harm, no one found hurt, one or a few residents.
F623 Notice Before Transfer or Discharge: risk of harm, no one found hurt, a pattern, several residents.

One citation dated July 11, 2024

F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

Five citations dated May 18, 2024

F825 Specialized Rehabilitation Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F692 Enough Food and Fluids: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F684 Quality of Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F550 Dignity and Resident Rights: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

One citation dated April 24, 2024

F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.

Four citations dated March 21, 2024

F838 Facility Wide Assessment of Needed Resources: risk of harm, no one found hurt, widespread, found on a complaint visit.
F725 Enough Nursing Staff: risk of harm, no one found hurt, widespread, found on a complaint visit.
F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F686 Pressure Ulcer (Bedsore) Care: residents were harmed, one or a few residents, found on a complaint visit.

Five citations dated Feb. 27, 2024

F760 Significant Medication Errors: immediate danger to residents, one or a few residents, found on a complaint visit.
F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F756 Monthly Drug Regimen Review: risk of harm, no one found hurt, widespread, found on a complaint visit.
F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F580 Telling the Family About a Change: residents were harmed, one or a few residents, found on a complaint visit.

Two citations dated Jan. 6, 2024

F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

Seven citations dated Dec. 21, 2023

F835 Run the Facility Effectively: risk of harm, no one found hurt, widespread, found on a complaint visit.
F725 Enough Nursing Staff: risk of harm, no one found hurt, widespread, found on a complaint visit.
F689 Accident Hazards and Supervision: immediate danger to residents, one or a few residents, found on a complaint visit.
F686 Pressure Ulcer (Bedsore) Care: immediate danger to residents, one or a few residents, found on a complaint visit.
F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F558 Meeting Residents' Needs and Preferences: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

Four citations dated Nov. 30, 2023

F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread, found on a complaint visit.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F727 Required Registered Nurse and Nursing Director: risk of harm, no one found hurt, widespread, found on a complaint visit.

Four citations dated Oct. 31, 2023

F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread, found on a complaint visit.
F725 Enough Nursing Staff: risk of harm, no one found hurt, widespread, found on a complaint visit.
F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

28 citations dated July 24, 2023

F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread.
F868 Quality Group Membership and Quarterly Meetings: risk of harm, no one found hurt, widespread.
F867 Ongoing Quality Review Group and Correction Plans: risk of harm, no one found hurt, widespread.
F847 Right to Refuse Binding Arbitration: risk of harm, no one found hurt, one or a few residents.
F837 Governing Body and Licensed Administrator: risk of harm, no one found hurt, widespread.
F835 Run the Facility Effectively: risk of harm, no one found hurt, widespread.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
F806 Food That Meets Allergies and Preferences: risk of harm, no one found hurt, widespread.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
F760 Significant Medication Errors: risk of harm, no one found hurt, one or a few residents.
F758 Psychotropic Drugs and PRN Orders: risk of harm, no one found hurt, one or a few residents.
F732 Post Daily Nurse Staffing Information: minimal risk to residents, widespread.
F727 Required Registered Nurse and Nursing Director: risk of harm, no one found hurt, widespread.
F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
F692 Enough Food and Fluids: risk of harm, no one found hurt, one or a few residents.
F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents.
F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents.
F680 Qualified Activities Director: risk of harm, no one found hurt, widespread.
F679 Activities That Meet Every Resident's Needs: risk of harm, no one found hurt, widespread.
F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents.
F656 A Complete Care Plan: risk of harm, no one found hurt, a pattern, several residents.
F655 Baseline Care Plan at Admission: risk of harm, no one found hurt, one or a few residents.
F638 Update Assessments Every Three Months: risk of harm, no one found hurt, one or a few residents.
F637 Reassess After a Major Change in Condition: risk of harm, no one found hurt, one or a few residents.
F636 Complete Assessments at Admission and Yearly: risk of harm, no one found hurt, one or a few residents.
F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents.
F558 Meeting Residents' Needs and Preferences: risk of harm, no one found hurt, one or a few residents.

Payment Denials and Fines

Date	Penalty	Amount
April 29, 2026	Fine	$175,800
April 29, 2026	Payment denial for new admissions	33 days
Feb. 13, 2026	Fine	$346,525
Feb. 13, 2026	Payment denial for new admissions	34 days
Nov. 30, 2023	Fine	$181,422
Nov. 30, 2023	Payment denial for new admissions	111 days

Ownership and Management of the Home

The home is run by Goldwater Care Management LLC (operational or managerial control).

The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 145239. Other homes in Illinois.