Goldwater Care Peoria Heights
5533 North Galena Road · Peoria Heights, IL · 61614 · 3096825428
94 certified beds For profit - Corporation Chain: Goldwater Care
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $346,525 in fines in the last 24 months.
- 5 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$346,525 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
RN staffing in the bottom 10% nationally
0.25 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.08 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.25 | 0.55–0.75 |
| Weekend hours / resident-day | 2.77 | ≈ weekday level |
| Nursing turnover / year | 49% | median 45% |
| Fines (3-yr window) | 2 · $527,947 |
Inspection citations (106 in the current record)
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Potential for harm · E April 29, 2026 · found via complaint
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.
Corrected April 30, 2026 · Resident Rights
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Potential for harm · D April 15, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 16, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 28, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 2, 2026 · Quality of Life and Care
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Immediate jeopardy · J February 13, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 16, 2026 · Quality of Life and Care
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Immediate jeopardy · J February 13, 2026 · found via complaint
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.
Corrected February 16, 2026 · Quality of Life and Care
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Immediate jeopardy · L February 13, 2026 · found via complaint
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected February 16, 2026 · Administration
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Actual harm · G February 13, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 10, 2026 · Resident Rights
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Actual harm · G February 13, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 16, 2026 · Quality of Life and Care
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Actual harm · G February 13, 2026 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected February 16, 2026 · Quality of Life and Care
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Potential for harm · D February 13, 2026 · found via complaint
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected February 16, 2026 · Resident Rights
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Potential for harm · E February 13, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected February 16, 2026 · Quality of Life and Care
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Potential for harm · F February 13, 2026 · found via complaint
Provide activities to meet all resident's needs.
Corrected February 16, 2026 · Quality of Life and Care
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Potential for harm · D February 13, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 2, 2026 · Quality of Life and Care
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Potential for harm · D February 13, 2026 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected February 16, 2026 · Quality of Life and Care
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Potential for harm · F February 13, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected February 16, 2026 · Nursing and Physician Services
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Potential for harm · F February 13, 2026 · found via complaint
Observe each nurse aide's job performance and give regular training.
Corrected February 16, 2026 · Nursing and Physician Services
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Potential for harm · E February 13, 2026 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 10, 2026 · Pharmacy Service
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Potential for harm · D February 13, 2026 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected February 16, 2026 · Pharmacy Service
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Potential for harm · D February 13, 2026 · found via complaint
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected February 16, 2026 · Administration
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Potential for harm · D February 13, 2026 · found via complaint
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected February 16, 2026 · Administration
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Potential for harm · F February 13, 2026 · found via complaint
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected February 16, 2026 · Administration
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Potential for harm · F February 13, 2026 · found via complaint
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected February 16, 2026 · Administration
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Potential for harm · D December 7, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected December 8, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 7, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 8, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F August 6, 2025 · found via complaint
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected August 7, 2025 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 13, 2026 | Fine | $346,525 |
| February 13, 2026 | Payment Denial | 34 days |
| November 30, 2023 | Fine | $181,422 |
| November 30, 2023 | Payment Denial | 111 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145239 · certified since February 2, 1972. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.