Goldwater Care Peoria Heights
Peoria Heights, Illinois · CCN 145239
64 surveys since 2011, 21 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 303
- Surveys
- 64
- Harm or worse
- 21
- Immediate jeopardy
- 7
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 94
- Ownership
- For profit - Limited Liability company
- Chain
- GOLDWATER CARE
- County
- Peoria
- Medicare-certified since
- 1972
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 1
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 140 for-profit facilities of 66–99 beds in Illinois.
Last survey on record
Jul 13, 2026
119 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.76 | 3.18 |
| Registered-nurse hours per resident day | 0.21 | — |
| Annual nurse turnover | 54.2% | 45.5% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $703,747 across 3 penalties
- Payment denials
- 3
- Special focus
- SFF Candidate
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J53.9% | K— | L10.8% |
| Actual harm | G107.9% | H— | I— |
| No harm, potential for more than minimal | D6148.0% | E1612.6% | F3326.0% |
| No harm, potential for minimal | A— | B— | C10.8% |
Most frequently cited here
In CMS’s current monthly file.
- F6897×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6866×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F8805×
Provide and implement an infection prevention and control program.
- F6904×
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- F7254×
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
In the surveyor’s words
From the most serious findings on record at Goldwater Care Peoria Heights, in the surveyor’s own words.
- Immediate jeopardy, widespreadF835Feb 13, 2026
Based on observation, interview, and record review, the facility failed to provide adequate administrative oversight to ensure the facility implemented policies for wound care, medication administration, treatment administration, quality assurance measures, and basic activities of daily resident care. These failures resulted in a facility-wide lack of supervision and care leading to residents experiencing worsening pressure ulcers, severe pain, a lack of resident care for gastrostomy tubes and pressure ulcer treatments with subsequent infections requiring hospitalization, untimely assistance with incontinent care and showers resulting in residents being left in soiled conditions for extended periods, missed medication administrations with significant medication errors, and not providing a… […]
- Immediate jeopardy, isolatedF686Feb 13, 2026
Based on interview and record review, the facility failed to identify, assess, and treat a facility-acquired pressure ulcer, prevent a pressure ulcer from worsening, administer wound treatments as ordered, develop and implement pressure relieving interventions and a pressure ulcer care plan for two of three residents (R4, R9) reviewed for pressure ulcers in the sample of 16. This failure resulted in R4 developing a facility acquired pressure ulcer and R4 and R9's wounds worsening without adequate treatment and being transferred to the hospital with lethargy, high fever and requiring extensive hospitalization for diagnoses of sepsis and a stage four decubitus pressure ulcer with osteomyelitis.These failures resulted in an Immediate Jeopardy. […]
- Immediate jeopardy, isolatedF693Feb 13, 2026
Based on interview and record review, the facility failed to provide physician ordered gastrostomy care including cleansing, laboratory monitoring, flushes, residual checks and tube insertion site assessments for a resident with an internal percutaneous endoscopic gastrostomy (PEG) tube for nutritional support for one of three residents (R9) reviewed for gastrostomy tubes (G-tube) in the sample of 16. This failure resulted in R9 transferring to the emergency room and being admitted to the hospital with fever, abdominal pain, diarrhea, nausea and vomiting, toxic appearance and a diagnosis of sepsis from multiple suspected sources including a g-tube site infection with pus filled drainage.These failures resulted in an Immediate Jeopardy. […]
- Immediate jeopardy, isolatedF760Feb 27, 2024
These failures resulted in three deficient practice statements. A. Based on interview and record review the facility failed to monitor laboratory tests results for a high-risk medication, Warfarin (anticoagulant) for one of two residents (R11) reviewed for anticoagulants in a sample of 42. This failure resulted in R11 being admitted to the hospital with a critical PT (Prothrombin level/normal 9.8-12.2 seconds) and INR (International Normalized Ratio/normal range 0.9-1.2 milligrams per deciliter). B. Based on interview and record review the facility failed to provide medications and discontinue a medication as ordered for 4 of 4 residents (R4, R8, R12 and R13) reviewed for medication administration. […]
- Immediate jeopardy, isolatedF686Dec 21, 2023
Based on interview, observation and record review, the facility failed to identify, assess, report and treat a facility-acquired pressure ulcer for one resident (R6); failed to administer wound treatment as ordered using proper infection control technique; failed to develop and implement pressure relieving interventions or care plan; failed to conduct a pressure ulcer development risk assessment for a resident identified as high risk for pressure ulcer development; and failed to develop a pressure ulcer care plan after a pressure ulcer developed for three of three residents (R1, R4, R6) reviewed for pressure ulcers in the sample of nine. These failures resulted in an Immediate Jeopardy. […]
Read 36 findings in full →The most serious and the most recent: 36 of 303 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 13, 2026Complaint1 finding
- Jun 17, 2026Complaint3 findings · 2 harm
- May 27, 2026Complaint1 finding · 1 harm
- Apr 29, 2026Standard and complaint20 findings · 2 harm
- Apr 15, 2026Complaint1 finding
- Feb 28, 2026Complaint1 finding
- Feb 13, 2026Complaint19 findings · 6 harm
- Dec 7, 2025Complaint2 findings
Show the 56 earlier surveys
- Aug 6, 2025Complaint2 findings
- Dec 7, 2024Complaint1 finding
- Oct 1, 2024Standard5 findings
- Jul 11, 2024Complaint1 finding
- May 18, 2024Complaint5 findings
- Apr 24, 2024Complaint1 finding
- Mar 21, 2024Complaint4 findings · 1 harm
- Feb 27, 2024Complaint5 findings · 2 harm
- Jan 6, 2024Complaint2 findings
- Dec 21, 2023Complaint7 findings · 2 harm
- Nov 30, 2023Complaint4 findings
- Oct 31, 2023Complaint4 findings
- Jul 24, 2023Standard28 findings
- Jun 21, 2023Complaint3 findings
- May 31, 2023Complaint1 finding
- Feb 8, 2023Complaint1 finding
- Oct 22, 2022Complaint1 finding
- Aug 12, 2022Standard10 findings
- Apr 16, 2022Complaint3 findings
- Feb 15, 2022Complaint1 finding · 1 harm
- Jan 25, 2022Complaint3 findings
- Jan 19, 2022Complaint3 findings
- Dec 14, 2021Complaint5 findings
- Oct 5, 2021Complaint2 findings
- Sep 7, 2021Complaint2 findings
- Sep 2, 2021Complaint4 findings
- Jun 17, 2021Standard22 findings
- Dec 19, 2020Complaint1 finding · 1 harm
- Nov 25, 2020Complaint1 finding
- Aug 20, 2020Complaint7 findings
- Feb 26, 2020Complaint1 finding · 1 harm
- Jan 28, 2020Complaint2 findings
- Oct 10, 2019Complaint1 finding
- Sep 6, 2019Standard8 findings
- Jul 17, 2019Complaint2 findings
- Jan 23, 2019Complaint2 findings
- Nov 7, 2018Complaint1 finding
- Oct 25, 2018Complaint1 finding
- Aug 31, 2018Standard12 findings
- Apr 21, 2018Complaint1 finding
- Jul 26, 2017Standard12 findings
- Sep 15, 2016Standard and complaint5 findings
- Jan 12, 2016Complaint1 finding
- Aug 15, 2015Standard18 findings
- Jun 10, 2015Complaint9 findings
- Apr 7, 2015Complaint2 findings
- Mar 24, 2015Complaint3 findings
- Feb 5, 2015Complaint2 findings
- Nov 10, 2014Complaint2 findings
- Jul 17, 2014Standard and complaint13 findings · 1 harm
- May 28, 2014Complaint2 findings
- Sep 5, 2013—8 findings · 1 harm
- Mar 25, 2013—1 finding
- Sep 6, 2012—1 finding
- Aug 16, 2012Standard3 findings
- Sep 22, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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