Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Goldwater Pontiac Nursing Home during CMS and state inspections, most recent first.
A resident, alert and oriented, reported $80 missing from her purse, which she kept in her room and only left unattended while sleeping. The resident and her family were certain the money was not misplaced, and staff confirmed her credibility. Despite an internal investigation and searches, the missing funds were not recovered, indicating a failure to protect the resident from misappropriation of money.
A resident who was alert and oriented reported $80 missing from her purse, which she kept in her room. The facility's investigation included interviews and searches but did not document review of available video surveillance or specify which staff were interviewed. The administrator stated that uncertainty about the date of the incident prevented review of surveillance footage, and the investigative file lacked required details.
A resident with severe cognitive impairment used a CPAP machine for several months without physician orders or care plan documentation. Staff confirmed the absence of orders and documentation, and the resident's CPAP filter was found dirty and in need of replacement, contrary to facility policy and manufacturer instructions.
A facility failed to remove two CNAs from resident care duties after an abuse allegation was made by a resident, who reported rough handling and verbal aggression. Despite the facility's policy requiring immediate removal of staff following such allegations, the CNAs continued working until a social media post prompted their suspension. The administrator initially misjudged the incident as a customer service issue, delaying appropriate action.
A facility failed to promptly notify a resident's family and physician of an abuse allegation after two CNAs were reported to have been rough while repositioning the resident, causing discomfort. The resident, who was cognitively intact, reported the incident immediately, but the facility delayed notification until the family posted on social media. The facility's policy requires timely notification in such cases, but documentation showed a delay in communication.
A resident reported rough handling by CNAs, causing pain and a popping sensation in the back and ribs. The incident was not reported to the state survey agency until two days later, after a family member posted about it on social media. The facility initially treated the complaint as a customer service issue, leading to a delay in reporting the abuse allegation.
The facility failed to provide necessary behavioral health services to a resident diagnosed with major depression, resulting in the resident being tearful, visibly shaking, and expressing despair. Despite having a care plan for psychosocial well-being, there were no medication orders for the resident's depression, and the resident's medical record lacked documentation of any behavioral health services.
The facility failed to track infections and conduct infection surveillance, affecting one resident who was not properly isolated for Norovirus. The resident was unaware of isolation requirements and had been out in public, despite physician orders for strict contact and droplet isolation.
The facility failed to maintain resident dignity, as evidenced by a CNA asking a resident about bowel movements in a public hallway, a cognitively impaired resident being isolated during meals without proper documentation, and a urinary drainage bag being left uncovered and visible from the hallway.
The facility failed to complete a self-administration of medication assessment for a resident. A resident was found with a medication cup containing several unidentified medications on the bedside table. The RN initially denied leaving the medications, and the DON confirmed that nurses should not leave medications at the bedside. Clinical records showed no physician order or assessment for self-administration, and the care plan required medications to be administered and monitored by an LPN or RN.
Facility staff failed to report allegations of abuse for a resident with severe cognitive impairments. The resident accused CNAs of physical abuse and exhibited aggressive behavior towards others, but these incidents were not reported to the Abuse Coordinator or Administrator as required by the facility's policy.
The facility failed to accurately code the MDS for three residents, leading to discrepancies in their medical records. One resident was incorrectly documented as having limited ROM, another's hospice care was not recorded, and a third was marked as having dialysis despite never undergoing the procedure.
The facility failed to assist two residents with shaving and nail care. One resident, who required supervision for personal hygiene, was observed with partially shaved facial hair and dirty, jagged fingernails. Another resident, who needed extensive assistance, had a quarter-inch growth of facial hair and expressed a need for help with shaving. Both residents' care plans documented their need for assistance, but the staff did not provide the necessary care.
The facility failed to ensure proper pressure ulcer wound treatments and implement pressure-relieving interventions for two residents. One resident with a chronic stage four pressure ulcer did not receive the ordered wound care and was not provided with an alternating pressure air mattress. Another resident, at risk for pressure ulcers, had an unreported stage two pressure ulcer discovered during an examination. These deficiencies highlight the facility's failure to follow physician orders, implement appropriate interventions, and ensure proper reporting and documentation.
The facility failed to limit as-needed psychotropic medications to 14 days or less for a resident. A physician's order for Lorazepam topical gel was not restricted to the 14-day period as required by the facility's policy. The DON confirmed that PRN psychotropic medications should be limited to 14 days or less.
The facility failed to administer insulin according to Physician Orders and Manufacturer's Recommendations for two residents. Insulin was administered without offering food, contrary to guidelines, resulting in a medication error rate of 5.88%.
A resident received a dose of Vancomycin despite a critical high trough level, as the nurse did not consult the physician directly before administration. The pharmacist later confirmed the dose should have been held, and subsequent lab results indicated acute kidney injury.
Failure to Protect Resident from Misappropriation of Money
Penalty
Summary
A resident who was alert and oriented to person, place, and time reported that $80 was missing from her purse, which she kept in her room and typically did not leave unattended except while sleeping. The resident stated she discovered the money was missing when she attempted to pay for a hair appointment and found only single bills remaining in her purse. She had previously withdrawn cash from her resident trust fund account, with records confirming multiple withdrawals and the denominations provided. The resident and her family both asserted that the money was not misplaced, and the resident recalled a prior incident, over six months earlier, when an unidentified person was observed going through her closet at night. The facility conducted an investigation, including interviews with the resident and staff, and searches of the resident's room, laundry, and common areas, but was unable to locate the missing funds. Staff confirmed the resident's credibility and orientation, and there was no history of dishonest behavior or prior accusations. The facility's policy affirms residents' rights to be free from misappropriation of property, defined as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent.
Failure to Conduct Thorough Investigation of Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of funds for one resident who was alert and oriented. The resident reported that $80 was missing from her purse, which she kept in her room and did not leave unattended except while sleeping. The resident stated she had received cash withdrawals from the business office and kept the money in her purse for personal use, such as hair appointments. The facility's investigative file documented that interviews were conducted with the resident, her family, and staff, and that searches of the resident's room, laundry, and common areas were performed, but the missing funds were not located. The facility replaced the missing money for the resident. However, the investigation lacked key elements. There was no documentation that video surveillance footage, which was available in the hallway near the resident's room, was reviewed as part of the investigation. The investigative file also did not specify which staff members were interviewed or provide details of those interviews. The administrator acknowledged that, due to uncertainty about the exact date the money went missing, video footage was not reviewed and that surveillance is only retained for 30 days. The facility's policy required a more comprehensive investigation, including attempts to interview all relevant individuals and review available evidence, which was not fully documented or completed in this case.
Failure to Obtain Physician Orders and Provide Proper CPAP Care
Penalty
Summary
The facility failed to obtain physician orders for the use and care of a CPAP machine for a resident with severe cognitive impairment. The CPAP machine was observed in the resident's room, and the resident reported issues obtaining replacement parts and showed a dirty filter covered in debris. Despite the resident's ongoing use of the CPAP for at least five to six months, there were no active physician orders or care plan documentation regarding its use or maintenance. Staff interviews confirmed that the resident had been using the CPAP without corresponding physician orders or documentation on the Treatment Administration Record (TAR). The facility's policy requires verification of physician orders and regular cleaning and maintenance of CPAP equipment, including filter replacement according to manufacturer instructions. The user manual for the CPAP also specifies that the device should only be used as instructed by a physician and that filters should be checked and replaced regularly. However, these procedures were not followed, as evidenced by the lack of orders, care plan documentation, and the presence of a dirty filter. The Director of Nursing acknowledged that the facility was unaware of the resident's CPAP use until the day prior to the survey and that appropriate orders and care planning had not been completed.
Failure to Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to prevent further abuse by allowing two Certified Nursing Assistants (CNAs), identified as V4 and V5, to continue working with residents after an abuse allegation was made against them. The facility's policy requires immediate removal of employees from work following an abuse allegation, but V4 and V5 were not suspended until two days after the incident was reported on social media. This oversight potentially affected 36 residents in the facility. The incident involved a resident, R1, who reported that V4 and V5 were rough while repositioning them in bed, causing pain and a popping sensation in their back and ribs. R1 also stated that the CNAs yelled at them. R1 reported this to a nurse, and the incident was further communicated to the facility's administrator, V1, by another resident, R6. Despite these reports, V4 and V5 continued to work on the unit until the social media post prompted their suspension. The facility's administrator, V1, initially considered the incident a customer service issue rather than an abuse allegation, as R1 did not express fear or claim intentional harm. However, V1 later acknowledged that R1's statements during the incident should have been treated as an abuse allegation, which would have necessitated immediate action to remove V4 and V5 from resident care duties. This misjudgment led to a delay in addressing the abuse allegation appropriately.
Failure to Timely Notify of Abuse Allegation
Penalty
Summary
The facility failed to timely notify a resident's representative and physician of an allegation of abuse involving a resident. The incident occurred when two Certified Nursing Assistants (CNAs) were reported to have been rough while repositioning the resident in bed, causing the resident to feel a pop in their back and ribs. The resident, who was cognitively intact, reported the incident to an unidentified nurse on the same day it occurred. However, there was no documentation that the resident's physician or family member was notified until two days later, after the resident's family member posted about the incident on social media. The facility's policy requires notification of the resident's representative and physician in cases of accidents resulting in injury or significant changes in the resident's condition. Despite this policy, the facility did not notify the relevant parties until after the social media post brought attention to the incident. The facility's initial report to the Illinois Department of Public Health confirmed the delay in notification, and the resident's medical records lacked documentation of timely communication with the physician and family member. The administrator acknowledged the delay, stating they were out of the facility on the day following the incident and only followed up with the resident two days later.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to timely notify the administrator, state survey agency, and local law enforcement of an allegation of abuse involving a resident. The facility's policy requires immediate reporting of any potential or actual abuse to the administrator and notification to the Illinois Department of Public Health within several hours, not exceeding 24 hours. However, the incident involving a resident who reported rough handling by two Certified Nursing Assistants (CNAs) was not reported to the state survey agency until two days later, after a family member posted the allegation on social media. Additionally, there was no documentation that the local law enforcement was notified. The incident occurred when the resident requested repositioning in bed, and the CNAs allegedly handled the resident roughly, causing the resident to feel a pop in the back and ribs. The resident reported the incident to a nurse and later to a family member, who then posted about it on social media. The resident's Minimum Data Set (MDS) indicated cognitive intactness, and the resident expressed ongoing pain following the incident. Despite the resident's statements being considered an abuse allegation, the facility initially treated it as a customer service issue, and the administrator did not report it as abuse until after the social media post. Interviews with staff revealed that the CNAs involved were aware of the resident's complaints and reported them to a Licensed Practical Nurse (LPN), who did not escalate the issue to the administrator. The administrator, upon learning of the incident from another resident, did not consider it an abuse allegation due to the resident's denial of intentional harm or fear. This misjudgment led to a delay in reporting the incident to the appropriate authorities, violating the facility's abuse prevention and reporting policy.
Failure to Provide Behavioral Health Services for Resident with Major Depression
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with major depression, resulting in the resident being tearful, visibly shaking, and expressing despair. The resident, who has diagnoses of Vascular Dementia without Behaviors, Anxiety Disorder, and Major Depression, was observed to be emotionally distressed and expressed feelings of loss and a desire to run away. Despite having a care plan that included interventions for psychosocial well-being, there were no medication orders for the resident's major depression, and the resident's medical record lacked documentation of any behavioral health services being provided to address the depression. The Social Service Director (SSD) stated that residents on psychotropic medications are typically referred to behavioral health services, but this was not done for the resident due to the resident being on hospice. The SSD was unaware of the resident's severe emotional distress and recent events. After conducting a Patient Health Questionnaire (PHQ-9) that indicated possible depression, the SSD contacted the resident's Power of Attorney (POA), who confirmed that the resident had been on an antidepressant before being placed on hospice. The facility's Hospice Service Agreement indicated that the facility should provide all necessary services to residents on hospice, but this was not adhered to in the resident's case.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to operationalize their Infection Prevention and Control Program by not tracking infections and conducting infection surveillance. The facility's policy required the identification, monitoring, tracking, and reporting of infections, as well as monitoring adherence to infection control practices. However, the Infection Preventionist provided documentation that lacked trending and infection surveillance, and there were incomplete data entries for type/location of infection, infectious organism, and isolation requirements. This failure affected one resident and had the potential to affect all 80 residents in the facility. One resident, who was supposed to be in strict contact and droplet isolation for Norovirus, was not properly isolated. Despite physician orders and progress notes indicating the need for strict isolation, only a sign for enhanced barrier precautions was on the resident's door. The resident, who was cognitively intact, was unaware of any isolation requirements and had been out in public. The Assistant Director of Nursing confirmed that the resident should have been on contact isolation, and the Infection Preventionist was conducting staff education on proper isolation procedures.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that residents are treated with respect and dignity, affecting three residents. One resident reported feeling embarrassed when a Certified Nurse's Assistant asked her if she had pooped in the hallway in front of others. Another resident with severe cognitive impairment was observed eating lunch alone in the lounge area, away from other residents, without documentation in the care plan explaining this isolation. The Assistant Director of Nursing was unsure why the resident was isolated, other than a vague statement about the resident taking food from other trays, which was not documented in the care plan. Additionally, a resident with a diagnosis of neuromuscular dysfunction of the bladder, requiring an indwelling urinary catheter, was observed with an uncovered urinary drainage bag hanging at the foot of the bed, visible from the doorway and hallway. The resident confirmed that staff routinely left the bag uncovered. Both the Director of Nursing and the Assistant Director of Nursing acknowledged that all urinary collection bags should be placed inside a dignity bag unless being drained, which was not done in this case.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to complete a self-administration of medication assessment for a resident (R29). On the morning of 05/15/24, R29 was observed with a medication cup containing several unidentified medications on the bedside table while resting in a recliner with eyes closed. A registered nurse (V12) later retrieved the medication cup and questioned R29 about not taking the medication. V12 initially stated that only a calcium tablet was left at the bedside, contradicting the observation of multiple medications. The Director of Nursing (V2) confirmed that nurses are required to watch residents take their medications and should not leave medications at the bedside. A review of R29's clinical records revealed no physician order or assessment for self-administration of medication, and the care plan indicated that medications should be administered and monitored by an LPN or RN.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility staff failed to report allegations of abuse to the Abuse Coordinator for a resident with severe cognitive impairments. The resident accused CNAs of punching them in the gut, but no physical evidence was found. Despite this, the incident was not reported to the Abuse Coordinator or the Administrator. Additionally, the resident exhibited aggressive behavior towards another resident and staff, including threats of physical harm, which was also not reported as required by the facility's Abuse Prevention and Reporting Policy. Interviews with staff revealed that they were aware of the reporting requirements but did not follow them. The Administrator confirmed that no allegations of abuse had been reported to them, and the Director of Nursing later counseled the staff involved. The facility's policy mandates immediate reporting of any incident, allegation, or suspicion of abuse to the Administrator, which was not adhered to in this case.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to discrepancies in their medical records. For Resident 43, the MDS dated 2/28/24 documented limited range of motion (ROM) in both upper and lower extremities, but the care plan dated 4/23/24 did not reflect this. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) confirmed that Resident 43 had full ROM, indicating the MDS was incorrectly coded. The MDS Coordinator also verified the error, noting that the MDS was completed before their tenure at the facility. Resident 53's MDS dated 3/29/24 failed to document hospice care, despite physician orders and the care plan indicating hospice admission for comfort measures. The resident confirmed being placed on hospice after a stroke but mentioned an improvement in condition. The MDS Coordinator acknowledged the coding error. Additionally, Resident 29's MDS incorrectly marked the resident as having dialysis, although interviews with the Director of Nursing (DON), ADON, and a Registered Nurse (RN) confirmed that the resident had a dialysis access port but had never undergone dialysis. The DON and ADON reviewed the MDS and agreed it was completed incorrectly.
Failure to Assist with Shaving and Nail Care
Penalty
Summary
The facility failed to assist with shaving and nail care for two residents who were unable to perform these activities of daily living independently. One resident, who had a self-care performance deficit and required supervision with touch assistance for personal hygiene, was observed with partially shaved facial hair and jagged fingernails with an accumulation of a black substance underneath them. Despite expressing a desire to be clean-shaven and needing help, the resident did not receive the necessary assistance. Another resident, who required extensive assistance for personal hygiene due to weakness, was observed with a quarter-inch growth of facial hair and expressed a need for someone to help with shaving. Both residents' care plans documented their need for assistance, but the staff failed to provide the required care.
Failure to Provide Proper Pressure Ulcer Care and Implement Interventions
Penalty
Summary
The facility failed to ensure proper pressure ulcer wound treatments and implement pressure-relieving interventions for two residents. One resident, identified as R51, had a chronic stage four pressure ulcer to the sacrum. Despite physician orders for specific wound care, the wound dressing did not contain the ordered silver calcium alginate, and the resident was not provided with an alternating pressure air mattress as required. Additionally, the resident was observed sitting in a wheelchair with a mechanical lift sling between their buttocks and the gel pressure cushion, which could interfere with pressure relief. The DON confirmed these deficiencies and acknowledged the oversight regarding the mattress and the improper use of scissors from the pocket without proper cleaning during wound care procedures. Another resident, identified as R13, was at risk for pressure ulcer development due to weight, mobility issues, bowel incontinence, and fragile skin. Despite being cognitively intact and dependent on staff for toileting needs, R13's medical record did not document any current wounds or wound treatment. However, R13 reported having wounds on her buttocks and legs, and an open stage two pressure ulcer was found on her right buttock during an examination. A CNA admitted to noticing the wound during pericare but did not report it, instead applying barrier cream over it. These deficiencies highlight the facility's failure to follow physician orders for wound care, implement appropriate pressure-relieving interventions, and ensure proper reporting and documentation of pressure ulcers. The lack of adherence to care plans and protocols resulted in inadequate care for residents with pressure ulcers, potentially leading to further complications.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days or less for one resident reviewed for psychotropic medications. Specifically, a physician's order dated April 5, 2024, for Lorazepam topical gel 1 mg per ml, to be applied every 4-6 hours as needed for anxiety or agitation, was not limited to the 14-day period as required by the facility's policy. The policy, dated February 1, 2018, mandates that PRN psychotropic medications should not be used beyond 14 days unless the prescribing practitioner provides a clinical rationale for extended use and the expected duration. On May 15, 2024, the Director of Nursing confirmed that PRN psychotropic medications, including Lorazepam, should be limited to 14 days or less.
Failure to Administer Insulin According to Physician Orders and Manufacturer's Recommendations
Penalty
Summary
The facility failed to administer medications according to Physician Orders and follow Manufacturer's Recommendations for medication administration for two residents. One resident had a blood glucose level of 156 and was supposed to receive 5 units of Lispro Insulin per sliding scale orders at 5:00 pm. However, the insulin was administered at 4:15 pm without offering any food, contrary to the manufacturer's instructions that Lispro should be administered 5-15 minutes prior to a meal. The resident was still not served any food 30 minutes after the insulin administration. Another resident had a blood glucose level of 154 and was supposed to receive 2 units of Novolog insulin per sliding scale orders. The insulin was administered at 4:05 pm without offering any food, and the resident was still not served supper 40 minutes after the insulin administration. The facility's Medication Administration General Guidelines state that medications should be administered as prescribed and in accordance with good nursing principles and practices.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents are free of significant medication errors by administering intravenous antibiotic medications without consulting the physician due to critical lab values. Specifically, a resident with a physician's order for Ceftriaxone and Vancomycin for a foot infection had a critical high vancomycin trough level of 43. Despite this, a registered nurse administered the Vancomycin dose without receiving confirmation from the physician, as there was no order to hold the medication if the lab trough was high. The nurse left a message with the physician's office but did not speak with anyone directly before administering the medication. The pharmacist later confirmed that the resident should not have received the dose based on the critical trough level and issued an order to hold the Vancomycin and draw daily trough levels until the level was below 20. Subsequent lab results indicated that the resident had a low glomerular filtration rate and elevated blood creatinine level, leading to a diagnosis of acute kidney injury. This incident highlights a significant lapse in following proper procedures for medication administration and lab result monitoring, directly impacting the resident's health.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pontiac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accolade Healthcare Of Pontiac | 2.4 mi | ★★★★★ | 4 | 0 |
| Evenglow Lodge | 2.7 mi | ★★★★★ | 0 | 0 |
| Fairview Haven | 11.6 mi | ★★★★★ | 0 | 0 |
| Flanagan Rehabilitation And Health Care Center | 12.2 mi | ★★★★★ | 3 | 0 |
| Arc At Streator | 19 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.