The Vardell Report.Goldwater Care Peoria Heights

Across 21 inspections from July 2023 to July 2026, state surveyors documented 117 findings at Goldwater Care Peoria Heights; 117 have a recorded correction; CMS lists 6 enforcement actions in the window.

Inspections

21

2023–2026, complaint and standard

Findings

117

Deficiencies cited by state inspectors

Corrected

117

Of 117 findings, with a recorded correction date

Penalties

6

3 fines; payment not published, 3 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 132026

   Complaint investigation

   1 finding

   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Jul 15, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 172026

   Complaint investigation

   3 findings

   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level GActual harmCorrected May 12, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jun 19, 2026
   • F620Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.Level DNo actual harm, potential for moreCorrected Jun 19, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. May 272026

   Complaint investigation

   1 finding

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jun 10, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Apr 292026

   Standard health inspection

   20 findings

   The same visit included a complaint investigation.

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level GActual harmCorrected Apr 30, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jun 25, 2026
   • F727Have 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.Level FNo actual harm, potential for moreCorrected Jun 4, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Apr 30, 2026
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jun 4, 2026
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Apr 30, 2026
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level FNo actual harm, potential for moreCorrected Apr 30, 2026
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level ENo actual harm, potential for moreCorrected Apr 30, 2026
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Apr 30, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 5, 2026
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 30, 2026

   Enforcement Action

   Civil money penalty, $175,800 imposed April 29, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 29, 2026, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed April 29, 2026. Status: Closed, June 25, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 29, 2026, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Apr 152026

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Apr 16, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Feb 282026

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 2, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Feb 132026

   Complaint investigation

   19 findings

   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level LImmediate jeopardyCorrected Feb 16, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Feb 16, 2026
   • F693Ensure 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.Level JImmediate jeopardyCorrected Feb 16, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level GActual harmCorrected Apr 10, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Feb 16, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Feb 16, 2026
   • F679Provide activities to meet all resident's needs.Level FNo actual harm, potential for moreCorrected Feb 16, 2026
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Feb 16, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Feb 16, 2026
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Feb 16, 2026
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level FNo actual harm, potential for moreCorrected Feb 16, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Feb 16, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Apr 10, 2026
   • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 2, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
   • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
   • F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Feb 16, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Dec 72025

   Complaint investigation

   2 findings

   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Dec 8, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 8, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Aug 62025

   Complaint investigation

   2 findings

   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level FNo actual harm, potential for moreCorrected Aug 7, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 7, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Dec 72024

    Complaint investigation

    1 finding

    • F584Honor 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.Level ENo actual harm, potential for moreCorrected Dec 13, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Oct 12024

    Standard health inspection

    5 findings

    • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Oct 25, 2024
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 25, 2024
    • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Oct 25, 2024
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Oct 25, 2024
    • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Oct 25, 2024

    Enforcement Action

    Civil money penalty, $225,242 imposed February 13, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 1, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed February 13, 2026. Status: Closed, April 16, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 1, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Jul 112024

    Complaint investigation

    1 finding

    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jul 27, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

13. May 182024

    Complaint investigation

    5 findings

    • F692Provide enough food/fluids to maintain a resident's health.Level ENo actual harm, potential for moreCorrected Jun 8, 2024
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 8, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 8, 2024
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 8, 2024
    • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Jun 8, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

14. Apr 242024

    Complaint investigation

    1 finding

    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected May 10, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

15. Mar 212024

    Complaint investigation

    4 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Apr 10, 2024
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Apr 11, 2024
    • F838Conduct 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.Level FNo actual harm, potential for moreCorrected Apr 10, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Apr 10, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

16. Feb 272024

    Complaint investigation

    5 findings

    • F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected May 3, 2024
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level GActual harmCorrected Apr 12, 2024
    • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level FNo actual harm, potential for moreCorrected Apr 12, 2024
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Apr 12, 2024
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 12, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

17. Jan 62024

    Complaint investigation

    2 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jan 19, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jan 19, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

18. Dec 212023

    Complaint investigation

    7 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Feb 13, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Feb 22, 2024
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Feb 13, 2024
    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Feb 13, 2024
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 13, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Feb 13, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 13, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

19. Nov 302023

    Complaint investigation

    4 findings

    The same visit included an infection control inspection.

    • F727Have 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.Level FNo actual harm, potential for moreCorrected Dec 17, 2023
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Dec 17, 2023
    • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Dec 17, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Dec 17, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

20. Oct 312023

    Complaint investigation

    4 findings

    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Nov 22, 2023
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 22, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Nov 22, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 22, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

21. Jul 242023

    Standard health inspection

    28 findings

    • F679Provide activities to meet all resident's needs.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F680Ensure the activities program is directed by a qualified professional.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F727Have 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.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F837Establish 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.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F584Honor 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.Level ENo actual harm, potential for moreCorrected Sep 14, 2023
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 14, 2023
    • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Sep 14, 2023
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
    • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
    • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Sep 14, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F758Implement 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.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
    • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Aug 30, 2023

    Enforcement Action

    Civil money penalty, $181,422 imposed November 30, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 24, 2023, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed November 30, 2023. Status: Closed, May 10, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 24, 2023, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Pressure Injury Care, Cited in Six Inspections

   Inspectors cited F686 in July 2023, December 2023, March 2024, February 2026, April 2026 and May 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F686 across all 21 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Six Inspections

   Inspectors cited F689 in July 2023, October 2023, December 2023, February 2026, February 2026 and June 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F689 across all 21 inspections, oldest to newest
3. 3

   Infection Control, Cited in Five Inspections

   Inspectors cited F880 in July 2023, October 2023, November 2023, October 2024 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F880 across all 21 inspections, oldest to newest
4. 4

   Continence and Catheter Care, Cited in Four Inspections

   Inspectors cited F690 in July 2023, January 2024, March 2024 and April 2026. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F690 across all 21 inspections, oldest to newest
5. 5

   Nursing Staff Levels, Cited in Four Inspections

   Inspectors cited F725 in October 2023, December 2023, March 2024 and February 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F725 across all 21 inspections, oldest to newest
6. 6

   Pharmacy Services, Cited in Four Inspections

   Inspectors cited F755 in February 2024, May 2024, July 2024 and February 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F755 across all 21 inspections, oldest to newest
7. 7

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in May 2024, February 2026 and April 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F550 across all 21 inspections, oldest to newest
8. 8

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in July 2023, December 2024 and April 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F584 across all 21 inspections, oldest to newest
9. 9

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in July 2023, October 2023 and December 2023. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232323232424242424242424252526262626262626F657 across all 21 inspections, oldest to newest
10. 10

    Provide activities to meet all resident's needs, Cited in Three Inspections

    Inspectors cited F679 in July 2023, February 2026 and April 2026. The agency describes it this way: Provide activities to meet all resident's needs. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F679 across all 21 inspections, oldest to newest
11. 11

    Nutrition and Hydration, Cited in Three Inspections

    Inspectors cited F692 in July 2023, May 2024 and February 2026. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F692 across all 21 inspections, oldest to newest
12. 12

    Citation F727, Cited in Three Inspections

    Inspectors cited F727 in July 2023, November 2023 and April 2026. The agency describes it this way: 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. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F727 across all 21 inspections, oldest to newest
13. 13

    Medication Error Rate, Cited in Three Inspections

    Inspectors cited F759 in November 2023, February 2024 and April 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F759 across all 21 inspections, oldest to newest
14. 14

    Significant Medication Errors, Cited in Three Inspections

    Inspectors cited F760 in July 2023, February 2024 and February 2026. This citation covers whether residents are free from significant medication errors. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F760 across all 21 inspections, oldest to newest
15. 15

    Medication Labeling and Storage, Cited in Three Inspections

    Inspectors cited F761 in July 2023, November 2023 and April 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F761 across all 21 inspections, oldest to newest
16. 16

    Administration, Cited in Three Inspections

    Inspectors cited F835 in July 2023, December 2023 and February 2026. This citation covers whether the home is run in a way that uses its resources effectively. The most serious of these was recorded at level L (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F835 across all 21 inspections, oldest to newest
17. 17

    Citation F868, Cited in Three Inspections

    Inspectors cited F868 in July 2023, October 2024 and February 2026. The agency describes it this way: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F868 across all 21 inspections, oldest to newest
18. 18

    Needs and Preferences, Cited in Two Inspections

    Inspectors cited F558 in July 2023 and December 2023. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F558 across all 21 inspections, oldest to newest
19. 19

    Protection From Abuse and Neglect, Cited in Two Inspections

    Inspectors cited F600 in January 2024 and April 2026. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F600 across all 21 inspections, oldest to newest
20. 20

    Reporting Suspected Abuse, Cited in Two Inspections

    Inspectors cited F609 in December 2025 and April 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F609 across all 21 inspections, oldest to newest
21. 21

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in August 2025 and April 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F610 across all 21 inspections, oldest to newest
22. 22

    Pre-Admission Screening, Cited in Two Inspections

    Inspectors cited F645 in October 2024 and April 2026. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F645 across all 21 inspections, oldest to newest
23. 23

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in July 2023 and April 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F656 across all 21 inspections, oldest to newest
24. 24

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in December 2023 and February 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F677 across all 21 inspections, oldest to newest
25. 25

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in May 2024 and February 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F684 across all 21 inspections, oldest to newest
26. 26

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in July 2023 and April 2026. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F695 across all 21 inspections, oldest to newest
27. 27

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in July 2023 and April 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F812 across all 21 inspections, oldest to newest
28. 28

    Antibiotic Use, Cited in Two Inspections

    Inspectors cited F881 in October 2024 and April 2026. This citation covers the home’s program for monitoring antibiotic use. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232323232424242424242424252526262626262626F881 across all 21 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in six inspections, most seriously at level J.

2. 02

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in six inspections, most seriously at level J.

3. 03

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in five inspections, most seriously at level F.

4. 04

   How is continence care scheduled, and how do you prevent urinary infections?

   Continence and Catheter Care: cited in four inspections, most seriously at level E.

5. 05

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   Nursing Staff Levels: cited in four inspections, most seriously at level F.

6. 06

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in four inspections, most seriously at level E.

7. 07

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in three inspections, most seriously at level G.

8. 08

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in three inspections, most seriously at level E.

9. 09

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in three inspections, most seriously at level D.

10. 10

    What changed after F679 was cited, and how do you check it now?

    Provide activities to meet all resident's needs: cited in three inspections, most seriously at level F.

11. 11

    How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

    Nutrition and Hydration: cited in three inspections, most seriously at level E.

12. 12

    What changed after F727 was cited, and how do you check it now?

    Citation F727: cited in three inspections, most seriously at level F.

13. 13

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in three inspections, most seriously at level E.

14. 14

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in three inspections, most seriously at level J.

15. 15

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in three inspections, most seriously at level E.

16. 16

    How long have the administrator and the director of nursing been in their roles?

    Administration: cited in three inspections, most seriously at level L.

17. 17

    What changed after F868 was cited, and how do you check it now?

    Citation F868: cited in three inspections, most seriously at level F.

18. 18

    How do you adjust rooms, schedules and routines to a resident’s needs and preferences?

    Needs and Preferences: cited in two inspections, most seriously at level D.

19. 19

    What happened after the abuse or neglect citation, and what changed in training or supervision?

    Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.

20. 20

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in two inspections, most seriously at level D.

21. 21

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in two inspections, most seriously at level D.

22. 22

    Was the required pre-admission screening done for every resident, and how is it tracked?

    Pre-Admission Screening: cited in two inspections, most seriously at level D.

23. 23

    How is a care plan written and reviewed here, and how do families take part in it?

    Care Plans: cited in two inspections, most seriously at level E.

24. 24

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in two inspections, most seriously at level E.

25. 25

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level G.

26. 26

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

27. 27

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in two inspections, most seriously at level F.

28. 28

    How do you track antibiotic use and decide when one is needed?

    Antibiotic Use: cited in two inspections, most seriously at level F.

29. 29

    What led to the 2026 fine, and has it been paid?

    A $175,800 civil money penalty was imposed April 29, 2026. CMS publishes the fine, not whether it has been paid. The record holds six enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Illinois state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Jul 24, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Oct 31, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Nov 30, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Dec 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Jan 6, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Feb 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Mar 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Apr 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection May 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Jul 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Oct 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Dec 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Aug 6, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Dec 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Feb 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Feb 28, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Apr 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Apr 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection May 27, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Jun 17, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Jul 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 145239

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.