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Nursing HomeMedicaid Investigative

Goldwater Care Peoria Heights

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

5533 North Galena Road, Peoria Heights, IL 6161494 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.8/5

based on 32 Google reviews

5
4
3
2
1
Goldwater Care Peoria Heights Nursing Home in Peoria Heights, IL — Street View
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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • High staff turnover (62%)
  • High RN turnover (80%)

Bottom 25% in IL · Critically understaffed (RN) · Worst in GOLDWATER CARE chain · $181,422 in fines

Source: Medicare data

What this means for your family

While some families report positive rehabilitation outcomes, the recent trend of negative reviews regarding basic hygiene and administrative responsiveness is concerning. We strongly recommend conducting an unannounced visit and specifically observing how quickly staff respond to call lights before making a decision.

Google Reviews

Google Reviews

32 reviews on Google
Goldwater Care Peoria Heights receives highly polarized feedback, with some families praising the homey atmosphere and dedicated staff, while others report severe neglect and administrative failures. Recent reviews highlight significant concerns regarding resident hygiene, slow response times for basic needs, and high staff turnover under current management.

Quality Themes

Tap a score for details
FoodN/AStaff5.0Clean7.0Activities8.0MedsN/AMemoryN/AComms2.0ValueN/A

Strengths

  • Clean, well-maintained building
  • Homey, welcoming atmosphere
  • Effective rehabilitation outcomes
  • Specific staff members praised for dedication

Concerns

  • Neglect of basic hygiene and resident needs (soiled diapers, lack of showers) (mentioned by 3 reviewers)
  • Inattentive or unresponsive staff/reception (mentioned by 3 reviewers)
  • High staff turnover and understaffing issues (mentioned by 3 reviewers)
  • Administrative incompetence or poor management (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'16(1)'19(1)'22(2)'24(3)'26(2)

Distribution · 33 analyzed

5
22
4
1
3
0
2
1
1
9
10 reviews posted between Feb 6, 2023Feb 11, 2023 · 10 were 5-star

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the recent feedback regarding staffing levels, how does the current management team ensure that residents receive consistent support with daily hygiene and personal care needs?
  • 2With the facility currently working to improve its CMS quality ratings, what specific steps is leadership taking to enhance communication and responsiveness with family members?
  • 3How does the team manage staff turnover to ensure that my loved one consistently interacts with familiar faces who understand their unique care preferences?
  • 4Can you walk me through the daily routine for residents, and how do you ensure that those who need extra assistance with showers or grooming are prioritized?
  • 5In the event of a medical change or emergency, what is your protocol for notifying family members, and how quickly can we expect a response from the nursing staff?
  • 6I’ve heard positive things about the rehabilitation outcomes here; how do you integrate those successful therapy practices into the overall daily care plan for long-term residents?

Personalized based on this facility's data


Key Review Excerpts

My mother came in to this facility not being able to walk or really even sit correctly. I am so excited that she can now walk and enjoy life how she needs to.

Long-term resident's family · 2020★★☆☆☆

I’ve been on a bedpan for 2 and 1/2 hours without getting help literally with lite on . Have not had a wash rag to wash my face or oral care since I’ve been here. Have went 3 weeks without a shower.

Resident · 2025☆☆☆☆

In just around 5 months of the new administration the census has plummeted from around 70 to the low 30s. The once great and family feeling environment has gone so stale.

Family member · 2024☆☆☆☆
Source: 32 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.25hrs
34%
Registered nurses for medical care
Total Nursing
3.08hrs
75%
All nurses + aides combined
Staff Turnover
49%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

5

measures

Worse Than Avg

7

measures

Mixed Results

5

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility87.9%
Worse than Avg
Here
87.9%
US
12.1%
IL
52.5%
Peoria
51.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility35.6%
Worse than Avg
Here
35.6%
US
19.4%
IL
21.1%
Peoria
17.3%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility30.5%
Worse than Avg
Here
30.5%
US
15.4%
IL
21.8%
Peoria
23.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility26.9%
Worse than Avg
Here
26.9%
US
15.3%
IL
15.9%
Peoria
17.6%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility18.4%
Mixed vs Avgs
Here
18.4%
US
19.5%
IL
18.3%
Peoria
24.2%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility97.5%
Better than Avg
Here
97.5%
US
95.5%
IL
91.8%
Peoria
96.3%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility40.5%
Worse than Avg
Here
40.5%
US
79.7%
IL
63.1%
Peoria
80.7%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility70.2%
Mixed vs Avgs
Here
70.2%
US
81.8%
IL
69.0%
Peoria
76.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.4%
Worse than Avg
Here
2.4%
US
1.6%
IL
2.4%
Peoria
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

29deficiencies
2penalties
Well above state avg (12.0)
62 complaint-triggered
$181,422 in fines

Families have filed multiple reports triggering 42 deficiencies, with ongoing problems in medication management, nursing staffing, and pressure ulcer prevention. The facility has had 122 total deficiencies across 17 surveys, with issues in abuse prevention, safety hazards, and infection control recurring repeatedly throughout recent years. While deficiencies show correction dates, the pattern of repeated violations in critical care areas suggests persistent operational challenges that families should carefully consider.

Feb 28, 2026Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Feb 13, 2026Complaint
19
0835Immediate jeopardy · WidespreadCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0686Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0693Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0550Actual harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0697Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0679Potential for harm · WidespreadCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0730Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0868Potential for harm · WidespreadCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0944Potential for harm · WidespreadCorrected

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0569Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0773Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

0777Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

Dec 7, 2025Complaint
2
0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Aug 6, 2025Complaint
2
0565Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Dec 7, 2024Complaint
1
0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

Oct 1, 2024Routine
19
0918Potential for harm · Widespread

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0868Potential for harm · WidespreadCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0881Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0291Potential for harm · WidespreadCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0355Potential for harm · WidespreadCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0211Potential for harm · Pattern

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0324Potential for harm · Pattern

Smoke Deficiencies

Provide properly protected cooking facilities.

0623Potential for harm · PatternCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0271Potential for harm · PatternCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0351Potential for harm · PatternCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0913Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure operating rooms are properly protected and written records are maintained and available for inspection.

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Federal Penalties

Fine

Nov 30, 2023

$181,422

Payment Denial

Nov 30, 2023

111-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Goldwater Care Peoria Heights

Organization Type

for profit

Chain Affiliation

Chain Name

Goldwater Care

Chain Size

11 facilities nationwide

Chain avg rating: 1.4/5 · Rank 6 of 11 (Worst)

Ownership & Management

Owners

Katzenstein, Meir

Owner

35%

Tversky, Aaron

Owner

35%

Berkowitz, David

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Meystel, Yosef

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Stachowiak, MelissaManaging Control - Governing BodyStewart, JasonManaging Control - Governing BodyTversky, AaronManaging Control - Governing BodySpector, JenniferOfficer / DirectorGoldwater Care Management LLCManager
Source: Medicare provider data

Contact

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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