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Complaint Investigation

Goldwater Care Peoria Heights

April 29, 2026 · Peoria Heights, IL · 5533 North Galena Road
Citations 1
CMS Rating 1/5
Beds 94
Provider ID 145239
Healthcare Facility
Goldwater Care Peoria Heights
Peoria Heights, IL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

GOLDWATER CARE PEORIA HEIGHTS in PEORIA HEIGHTS, IL — inspection on April 29, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0584
Resident Rights Deficiencies

limited to receiving treatment and supports for daily living safely.

record review, observation, and interview the facility failed to provide a clean environment for five

Electronic Health Record documents R14 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Acute Kidney Failure, Diabetes, and Heart Failure. On 4/27/26 at 11:16 AM, V22 (R14's family member) reported R14 was transferred to a different facility on 4/20/26. V22 reported during R14's stay R14 had gotten another resident's feces on R14's pants while using the shared bathroom. V22 reported the bathroom had feces on the floor and toilet and R14 could not wait to go to the bathroom so he got the feces on his pants. On 4/29/26 at 9:06 AM, R45 reported he was R14's roommate prior to R14's discharge from the facility. R45 reported R14's previous roommate was R24, R24 has a colostomy bag, and R24 cleans the colostomy bag in the bathroom. On 4/29/26 at 9:30 AM, R24's bathroom had feces splattered on the toilet and in the sink.

There was also undigested food particles on the drain guard of the sink. On 4/29/26 at 9:30 AM, V17 Maintenance Director reported R24 has a colostomy bag, cleans the colostomy bag in the sink, and stated, I wish (R24) wouldn't do that. On 4/29/26 at 9:40 AM, V25 Housekeeping Director reported she is aware R24 cleans his colostomy in the bathroom sink and has instructed housekeeping staff to check R24's bathroom several times a day to be sure it is clean. V25 reported this information was only relayed verbally and there is not any type of tracking to indicate how often the bathroom is checked and cleaned. On 4/29/26 at 9:48 AM, R24 reported he empties and cleans his colostomy bag and staff help sometimes.

R24's care plan intervention with a revision date of 3/19/26 documents, Provide ostomy care daily and [as needed]. On 4/29/26 at 10:17 AM, V25 Housekeeping Director reported it has been discussed in multiple meetings with administration and department heads about R24 emptying and cleaning his colostomy bag himself in the bathroom and leaving feces on the floor, toilet, and sink. On 4/29/26 at 1:43 PM V2 DON/Director of Nursing confirmed R24, R20, R32, and R42 all share a bathroom.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PEORIA HEIGHTS, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GOLDWATER CARE PEORIA HEIGHTS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.