Facility profile · CCN 145239
Goldwater Care Peoria Heights
85 federal citations on record , including 3 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $181,422.
Record summary
Federal record · Q1 202685
Total citations
75
Last 3 years
5
Actual harm+
2
Federal penalties
$181,422
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
85 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Dec 7, 2025 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Dec 7, 2025 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint |
| Aug 6, 2025 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Aug 6, 2025 | F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | F | Complaint |
| Dec 7, 2024 | F584 | 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. | E | Complaint |
| Oct 1, 2024 | F881 | Implement a program that monitors antibiotic use. | F | Standard |
| Oct 1, 2024 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Oct 1, 2024 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | Standard |
| Oct 1, 2024 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
| Oct 1, 2024 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | E | Standard |
| Jul 11, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| May 18, 2024 | F825 | Provide or get specialized rehabilitative services as required for a resident. | D | Complaint |
| May 18, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| May 18, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | E | Complaint |
| May 18, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| May 18, 2024 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint |
| Apr 24, 2024 | F759 | Ensure medication error rates are not 5 percent or greater. | E | Complaint |
| Mar 21, 2024 | F838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | F | Complaint |
| Mar 21, 2024 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Complaint |
| Mar 21, 2024 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E | Complaint |
| Mar 21, 2024 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint |
| Feb 27, 2024 | F760 | Ensure that residents are free from significant medication errors. | J | Complaint |
| Feb 27, 2024 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint |
| Feb 27, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | F | Complaint |
| Feb 27, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint |
| Feb 27, 2024 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | G | Complaint |
| Jan 6, 2024 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint |
| Jan 6, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Dec 21, 2023 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F | Complaint |
| Dec 21, 2023 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Complaint |
| Dec 21, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint |
| Dec 21, 2023 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | J | Complaint |
| Dec 21, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Dec 21, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Dec 21, 2023 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Complaint |
| Nov 30, 2023 | F880 | Provide and implement an infection prevention and control program. | F | Complaint |
| Nov 30, 2023 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Complaint |
| Nov 30, 2023 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint |
| Nov 30, 2023 | F727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | F | Complaint |
| Oct 31, 2023 | F880 | Provide and implement an infection prevention and control program. | F | Complaint |
| Oct 31, 2023 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Complaint |
| Oct 31, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Oct 31, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Jul 24, 2023 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Jul 24, 2023 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | Standard |
| Jul 24, 2023 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Standard |
| Jul 24, 2023 | F847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | D | Standard |
| Jul 24, 2023 | F837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | F | Standard |
| Jul 24, 2023 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F | Standard |
| Jul 24, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Jul 24, 2023 | F806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | F | Standard |
| Jul 24, 2023 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Standard |
| Jul 24, 2023 | F760 | Ensure that residents are free from significant medication errors. | D | Standard |
| Jul 24, 2023 | F758 | 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. | D | Standard |
| Jul 24, 2023 | F732 | Post nurse staffing information every day. | C | Standard |
| Jul 24, 2023 | F727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | F | Standard |
| Jul 24, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Jul 24, 2023 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Jul 24, 2023 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Jul 24, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Jul 24, 2023 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Jul 24, 2023 | F680 | Ensure the activities program is directed by a qualified professional. | F | Standard |
| Jul 24, 2023 | F679 | Provide activities to meet all resident's needs. | F | Standard |
| Jul 24, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Jul 24, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard |
| Jul 24, 2023 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Jul 24, 2023 | F638 | Assure that each resident’s assessment is updated at least once every 3 months. | D | Standard |
| Jul 24, 2023 | F637 | Assess the resident when there is a significant change in condition | D | Standard |
| Jul 24, 2023 | F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Standard |
| Jul 24, 2023 | F584 | 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. | E | Standard |
| Jul 24, 2023 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
| Jun 21, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Jun 21, 2023 | F584 | 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. | F | Complaint |
| Jun 21, 2023 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| May 31, 2023 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint |
| Aug 12, 2022 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D | Standard |
| Aug 12, 2022 | F791 | Provide or obtain dental services for each resident. | D | Standard |
| Aug 12, 2022 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard |
| Aug 12, 2022 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Aug 12, 2022 | F688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | E | Standard |
| Aug 12, 2022 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Aug 12, 2022 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Aug 12, 2022 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Aug 12, 2022 | F557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D | Standard |
| Aug 12, 2022 | F553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | E | Standard |
Federal enforcement history
Federal regulators have imposed 2 enforcement actions against this facility, including 1 civil money penalties totaling $181,422 and 1 payment-denial actions spanning 111 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Nov 30, 2023 | Fine | $181,422 | — |
| Nov 30, 2023 | Payment Denial | — | Jan 20, 2024 · 111 days |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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