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.
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)
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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
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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
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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
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Potential for harm · F September 10, 2025 · found via complaint
Provide training in compliance and ethics.
Corrected September 11, 2025 · Administration
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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
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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
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Potential for harm · D March 7, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected March 10, 2025 · Resident Assessment and Care Planning
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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
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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
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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
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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
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Potential for harm · D March 7, 2025
Provide and implement an infection prevention and control program.
Corrected March 10, 2025 · Infection Control
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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
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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
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Potential for harm · D April 18, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected May 10, 2024 · Resident Assessment and Care Planning
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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
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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
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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
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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
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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
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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
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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
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Potential for harm · F April 18, 2024
Provide and implement an infection prevention and control program.
Corrected May 10, 2024 · Infection Control
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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
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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
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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.