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.
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)
-
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
-
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
-
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
-
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
-
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
-
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.