Facility Watch Inspection records for every certified US nursing home

Goldwater Care Peoria Heights

5533 North Galena Road
Peoria Heights, IL 61614
(309) 682-5428

Special Focus Facility — SFF Candidate
CCN
145239
Certified beds
94
Ownership
For profit - Corporation
Chain
Goldwater Care

Nurse staffing

2.11
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.17 hours per resident per day

Nursing staff turnover: 49% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 29, 2026

1 citation · from a complaint investigation · Health
E
F0584 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has plan of correction · corrected April 30, 2026

Inspected April 15, 2026

1 citation · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected April 16, 2026

Inspected February 28, 2026

1 citation · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 2, 2026

Inspected February 13, 2026

19 citations · from a complaint investigation · Health
D
F0569 No actual harm with potential for more than minimal harm · Isolated

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Deficient, Provider has date of correction · corrected February 16, 2026
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 2, 2026
D
F0692 No actual harm with potential for more than minimal harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected February 16, 2026
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected February 16, 2026
D
F0773 No actual harm with potential for more than minimal harm · Isolated

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Deficient, Provider has date of correction · corrected February 16, 2026
D
F0777 No actual harm with potential for more than minimal harm · Isolated

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

Deficient, Provider has date of correction · corrected February 16, 2026
E
F0677 No actual harm with potential for more than minimal harm · Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected February 16, 2026
E
F0755 No actual harm with potential for more than minimal harm · Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected April 10, 2026
F
F0679 No actual harm with potential for more than minimal harm · Widespread

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected February 16, 2026
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected February 16, 2026
F
F0730 No actual harm with potential for more than minimal harm · Widespread

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected February 16, 2026
F
F0868 No actual harm with potential for more than minimal harm · Widespread

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Deficient, Provider has date of correction · corrected February 16, 2026
F
F0944 No actual harm with potential for more than minimal harm · Widespread

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected February 16, 2026
G
F0550 Actual harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected April 10, 2026
G
F0684 Actual harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected February 16, 2026
G
F0697 Actual harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected February 16, 2026
J
F0686 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected February 16, 2026
J
F0693 Immediate jeopardy to resident health or safety · Isolated

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Deficient, Provider has date of correction · corrected February 16, 2026
L
F0835 Immediate jeopardy to resident health or safety · Widespread

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Deficient, Provider has date of correction · corrected February 16, 2026

Inspected December 7, 2025

2 citations · from a complaint investigation · Health
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected December 8, 2025
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected December 8, 2025

Inspected August 6, 2025

2 citations · from a complaint investigation · Health
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected August 7, 2025
F
F0565 No actual harm with potential for more than minimal harm · Widespread

Honor the resident's right to organize and participate in resident/family groups in the facility.

Deficient, Provider has date of correction · corrected August 7, 2025

Inspected December 7, 2024

1 citation · from a complaint investigation · Health
E
F0584 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected December 13, 2024

Inspected October 1, 2024

5 citations · Health
D
F0645 No actual harm with potential for more than minimal harm · Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected October 25, 2024
E
F0623 No actual harm with potential for more than minimal harm · Pattern

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected October 25, 2024
F
F0868 No actual harm with potential for more than minimal harm · Widespread

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Deficient, Provider has date of correction · corrected October 25, 2024
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected October 25, 2024
F
F0881 No actual harm with potential for more than minimal harm · Widespread

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected October 25, 2024

Inspected July 11, 2024

1 citation · from a complaint investigation · Health
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected July 27, 2024

Inspected May 18, 2024

5 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected June 8, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected June 8, 2024
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected June 8, 2024
D
F0825 No actual harm with potential for more than minimal harm · Isolated

Provide or get specialized rehabilitative services as required for a resident.

Deficient, Provider has date of correction · corrected June 8, 2024
E
F0692 No actual harm with potential for more than minimal harm · Pattern

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected June 8, 2024

Inspected April 24, 2024

1 citation · from a complaint investigation · Health
E
F0759 No actual harm with potential for more than minimal harm · Pattern

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected May 10, 2024

Inspected March 21, 2024

4 citations · from a complaint investigation · Health
E
F0690 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected April 10, 2024
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected April 11, 2024
F
F0838 No actual harm with potential for more than minimal harm · Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Deficient, Provider has date of correction · corrected April 10, 2024
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected April 10, 2024

Inspected February 27, 2024

5 citations · from a complaint investigation · Health
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected April 12, 2024
E
F0755 No actual harm with potential for more than minimal harm · Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected April 12, 2024
F
F0756 No actual harm with potential for more than minimal harm · Widespread

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected April 12, 2024
G
F0580 Actual harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected April 12, 2024
J
F0760 Immediate jeopardy to resident health or safety · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected May 3, 2024

Inspected January 6, 2024

2 citations · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected January 19, 2024
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected January 19, 2024

Inspected December 21, 2023

7 citations · from a complaint investigation · Health
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected February 13, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected February 13, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected February 13, 2024
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected February 13, 2024
F
F0835 No actual harm with potential for more than minimal harm · Widespread

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Deficient, Provider has date of correction · corrected February 13, 2024
J
F0686 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected February 13, 2024
J
F0689 Immediate jeopardy to resident health or safety · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected February 22, 2024

Inspected November 30, 2023

4 citations · from a complaint investigation · Health
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected December 17, 2023
E
F0761 No actual harm with potential for more than minimal harm · Pattern

Ensure 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.

Deficient, Provider has date of correction · corrected December 17, 2023
F
F0727 No actual harm with potential for more than minimal harm · Widespread

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Deficient, Provider has date of correction · corrected December 17, 2023
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected December 17, 2023

Inspected October 31, 2023

4 citations · from a complaint investigation · Health
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected November 22, 2023
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected November 22, 2023
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected November 22, 2023
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected November 22, 2023

Inspected July 24, 2023

28 citations · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected September 14, 2023
D
F0636 No actual harm with potential for more than minimal harm · Isolated

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Deficient, Provider has date of correction · corrected September 14, 2023
D
F0637 No actual harm with potential for more than minimal harm · Isolated

Assess the resident when there is a significant change in condition

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0638 No actual harm with potential for more than minimal harm · Isolated

Assure that each resident’s assessment is updated at least once every 3 months.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected September 14, 2023
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected September 14, 2023
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0692 No actual harm with potential for more than minimal harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0758 No actual harm with potential for more than minimal harm · Isolated

Implement 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.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected August 30, 2023
D
F0847 No actual harm with potential for more than minimal harm · Isolated

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Deficient, Provider has date of correction · corrected September 14, 2023
E
F0584 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected September 14, 2023
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected September 14, 2023
E
F0761 No actual harm with potential for more than minimal harm · Pattern

Ensure 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.

Deficient, Provider has date of correction · corrected September 14, 2023
F
F0679 No actual harm with potential for more than minimal harm · Widespread

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0680 No actual harm with potential for more than minimal harm · Widespread

Ensure the activities program is directed by a qualified professional.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0727 No actual harm with potential for more than minimal harm · Widespread

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0806 No actual harm with potential for more than minimal harm · Widespread

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0835 No actual harm with potential for more than minimal harm · Widespread

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0837 No actual harm with potential for more than minimal harm · Widespread

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0867 No actual harm with potential for more than minimal harm · Widespread

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0868 No actual harm with potential for more than minimal harm · Widespread

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Deficient, Provider has date of correction · corrected August 30, 2023
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected August 30, 2023

Inspected June 21, 2023

3 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected July 6, 2023
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected July 6, 2023
F
F0584 No actual harm with potential for more than minimal harm · Widespread

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected July 6, 2023

Inspected August 12, 2022

10 citations · Health
D
F0557 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Deficient, Provider has date of correction · corrected August 26, 2022
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected August 26, 2022
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected August 26, 2022
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected August 26, 2022
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected August 26, 2022
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected August 26, 2022
D
F0791 No actual harm with potential for more than minimal harm · Isolated

Provide or obtain dental services for each resident.

Deficient, Provider has date of correction · corrected August 26, 2022
D
F0921 No actual harm with potential for more than minimal harm · Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected August 26, 2022
E
F0553 No actual harm with potential for more than minimal harm · Pattern

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Deficient, Provider has date of correction · corrected August 26, 2022
E
F0688 No actual harm with potential for more than minimal harm · Pattern

Provide 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.

Deficient, Provider has date of correction · corrected August 26, 2022

Penalties

DateTypeAmount
February 13, 2026Fine$346,525
February 13, 2026Payment Denial · 34 days
November 30, 2023Fine$181,422
November 30, 2023Payment Denial · 111 days

Ownership transfers

EffectiveSellerBuyer
12/01/2024Midwest Health Operations LLCGoldwater Care Peoria Heights LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.