Goldwater Care Peoria Heights: Wound Care Failures - IL
The resident, identified in inspection records only as R2, was admitted to the facility on March 10, 2026, transferred from a hospital. R2's family member, speaking to inspectors on May 26, said that within roughly a week of admission, R2 became dehydrated and had to be taken to the emergency room by ambulance. The pressure sores, the family member said, deepened significantly during R2's stay. "Deep enough to place two eggs inside," the family member told inspectors, describing the coccyx wound.
The family member also said staff did not tell them R2 had pressure ulcers until a couple of days after admission, and that staff "were not very good about turning or repositioning R2."
The Assistant Director of Nursing, who also served as the facility's wound nurse, told inspectors on May 27 that she had been on vacation and was not made aware of R2's pressure ulcers until March 13. When she assessed R2 that day, she found a stage two pressure ulcer on the right buttocks, a stage two on the left buttocks, and a stage three at the coccyx. She confirmed that R2's electronic medical record contained no prior skin assessment with wound measurements, no detailed descriptions of the ulcer sites, and no treatment orders.
None had been placed since admission.
The Director of Nursing acknowledged to inspectors on May 26 that residents should receive skin assessments upon admission and that any identified wounds should be documented with measurements and descriptions. Treatment, the Director of Nursing said, should be initiated upon admission. The Director of Nursing confirmed there was no treatment order in place for R2's wounds until March 13 and said there was no documentation in the medical record that a physician had ever been contacted about the wounds before that date.
The Medical Director told inspectors he had not been notified about R2's wounds on admission. He said directly: if he had been notified, treatment orders would have been put in place to prevent the wounds from worsening.
Treatment did begin on March 13, with hydrocolloid dressings ordered for Mondays, Wednesdays, and Fridays, and as needed if soiled or dislodged. A nurse progress note from March 17 documented that the dressings were becoming dislodged and not staying in place. The treatment was updated to silicone foam dressings, three times weekly.
The following evening, March 18 at 8:48 PM, R2's oxygen saturation dropped abruptly. Levels fell to between 60 and 74 percent. Staff repositioned R2, elevated the head of the bed, administered suctioning, nebulizer treatments, and oxygen at concentrations up to 40 percent, and applied a Venturi mask. Respiratory therapy intervened. The oxygen saturation remained unstable, fluctuating between 78 and 90 percent. The Assistant Director of Nursing was notified and agreed R2 needed to go to the hospital.
Emergency medical transport took R2 that night.
Hospital records dated March 18 document that R2 arrived with an unstageable pressure injury at the coccyx extending into the sacrum, measuring 8 centimeters by 6 centimeters. The wound base was 50 percent pink tissue, 40 percent purple tissue, and 10 percent brown. There was no undermining, no tunneling, scant serosanguinous drainage, and no odor. The surrounding skin was intact.
Federal inspectors cited the facility for failing to provide necessary care and services to prevent a decline in R2's condition, with actual harm beginning March 16, 2026. The inspection was conducted as a complaint investigation on May 27, 2026.
R2's family member described watching the wound deepen over days in a facility that, by the Medical Director's own account, never called him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Peoria Heights from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
GOLDWATER CARE PEORIA HEIGHTS in PEORIA HEIGHTS, IL was cited for violations during a health inspection on May 27, 2026.
The resident, identified in inspection records only as R2, was admitted to the facility on March 10, 2026, transferred from a hospital.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.