Goldwater Care Roseville
145 S Chamberlain St, Box 770 · Roseville, IL · 61473 · 3094262134
99 certified beds For profit - Limited Liability company Chain: Goldwater Care
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $7,332 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
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
1 immediate-jeopardy citation 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.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
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: 2 of 5
| Total nurse hours / resident-day | 3.81 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.55 | 0.55–0.75 |
| Weekend hours / resident-day | 3.65 | ≈ weekday level |
| Nursing turnover / year | 49% | median 45% |
| Fines (3-yr window) | 2 · $71,533 |
Inspection citations (39 in the current record)
-
Immediate jeopardy · L September 10, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected September 11, 2025 · Environmental
-
Potential for harm · F September 10, 2025 · 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 September 11, 2025 · Resident Rights
-
Potential for harm · F September 10, 2025 · found via complaint
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected September 11, 2025 · Administration
-
Potential for harm · F September 10, 2025 · found via complaint
Provide training in compliance and ethics.
Corrected September 11, 2025 · Administration
-
Actual harm · H June 3, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected June 8, 2025 · Environmental
-
Potential for harm · F June 3, 2025 · found via complaint
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected June 8, 2025 · Administration
-
Potential for harm · D March 7, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected March 10, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D March 7, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected March 10, 2025 · Quality of Life and Care
-
Potential for harm · D March 7, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected March 10, 2025 · Quality of Life and Care
-
Potential for harm · E March 7, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected March 10, 2025 · Quality of Life and Care
-
Potential for harm · D March 7, 2025
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.
Corrected March 10, 2025 · Pharmacy Service
-
Potential for harm · D March 7, 2025
Provide and implement an infection prevention and control program.
Corrected March 10, 2025 · Infection Control
-
Potential for harm · D February 19, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D February 19, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected February 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D April 18, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected May 10, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D April 18, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected May 10, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D April 18, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 10, 2024 · Quality of Life and Care
-
Potential for harm · D April 18, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected May 10, 2024 · Quality of Life and Care
-
Potential for harm · D April 18, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected May 10, 2024 · Quality of Life and Care
-
Potential for harm · D April 18, 2024
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.
Corrected May 10, 2024 · Pharmacy Service
-
Potential for harm · D April 18, 2024
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected May 10, 2024 · Administration
-
Potential for harm · F April 18, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 10, 2024 · Nutrition and Dietary
-
Potential for harm · F April 18, 2024
Provide and implement an infection prevention and control program.
Corrected May 10, 2024 · Infection Control
-
Potential for harm · F April 18, 2024
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected May 10, 2024 · Nursing and Physician Services
-
No harm found · C April 18, 2024
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected May 10, 2024 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 3, 2025 | Fine | $7,332 |
| November 15, 2023 | Fine | $64,201 |
Better-scoring options nearby
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 146020 · certified since April 1, 2002. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.