Cycle 1
Health 2024-05-16 · Fire 2024-05-16
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Pontiac, IL
Goldwater Pontiac Nursing Home
2-star overall rating with 3-star inspections with $13,635 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1225 South Ewing Drive, Pontiac, IL
(815) 844-5121
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Goldwater Care
Operator or chain grouping
Approved since
1997-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.13
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
2.46
CMS adjusted total nurse staffing hours
Case-mix index
1.74
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,882
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.03
Baseline 17.79% · Performance 19.10% · Measure score 5.03 · Achievement 5.03 · Improvement 0
Healthcare-associated infections
0
Baseline 7.34% · Performance 8.37% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.84
Performance 48.00% · Measure score 3.84 · Achievement 3.84 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 4.05 hours · Performance 2.46 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.94% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 12.93% · Lower 95% interval 8.14% |
| Discharge to community | 47.13% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 43.86% · Lower 95% interval 37.85% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.15% |
95.27%
2.9 pts better
|
Numerator 53 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 32.61% |
53.69%
21.1 pts worse
|
Numerator 15 · Denominator 46 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 20 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 3 · Denominator 54 · Adjusted rate 7.92% |
| Healthcare-associated infections requiring hospitalization | 8.37% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 10.17% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 8.65% |
8.2%
0.5 pts better
|
Numerator 9 · Denominator 104 |
| Staff flu vaccination coverage | 13.76% |
42%
28.2 pts worse
|
Numerator 15 · Denominator 109 |
| Discharge function score | 36.96% |
56.45%
19.5 pts worse
|
Numerator 17 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 91.3% |
96.28%
5 pts worse
|
Numerator 21 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 3 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
89.6%
6.4 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 94.9% · Q3 98.8% · Q4 92.9% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.2% |
91.6%
3.4 pts worse
|
95.5%
7.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.3%
2.2 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 6.3% · Q3 7.1% · Q4 7.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 98.7% |
50.3%
48.4 pts worse
|
11.4%
87.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.5%
2.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.6% · Q3 4.2% · Q4 1.4% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
18.5%
7 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 23.6% · Q3 23.0% · Q4 28.2% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
22.8%
7.8 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 16.1% · Q3 11.7% · Q4 13.0% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.2% |
17.2%
About the same
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 16.8% · Q3 23.6% · Q4 10.0% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
15.0%
0.8 pts worse
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 14.1% · Q3 16.7% · Q4 12.5% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.1%
0.5 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
21.3%
8.7 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 36.9% · Q3 24.8% · Q4 29.3% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.2%
1.6 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.3% · Q3 4.3% · Q4 3.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.8% |
68.8%
7 pts better
|
81.7%
5.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 72.7% · Q3 62.5% · Q4 63.6% · 4Q avg 75.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
14.0%
6.1 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.0% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
63.0%
24.3 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.9% |
26.2%
14.3 pts better
|
23.9%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 9.3% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-28 · Fire 2023-07-28
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-08-12 · Fire 2022-08-12
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-16
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-05-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-05-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-07
F · Potential for more than minimal harm
2024-05-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-26
F · Potential for more than minimal harm
2023-07-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-07-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-07
E · Potential for more than minimal harm
2023-07-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-07
F · Potential for more than minimal harm
2022-08-12
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-08-29
F · Potential for more than minimal harm
2022-08-12
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-08-29
F · Potential for more than minimal harm
2022-08-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-08-29
F · Potential for more than minimal harm
2022-08-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-08-29
F · Potential for more than minimal harm
2022-08-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-08-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-08-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-08-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-08-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-21
E · Potential for more than minimal harm
2024-11-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-02
G · Actual harm
2024-05-16
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-21
E · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-07-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-28
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-28
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-28
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-05-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-11
F · Potential for more than minimal harm
2022-08-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-08-12
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-08-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-08-24
Penalties and ownership
What sits behind the stars
$13,635
2023-06-12
Fine
Fine · fine $13,635
Fine
Ownership
Katzenstein, Meir
5% Or Greater Direct Ownership Interest · Individual
Yosef Meystel Declaration Of Tr Of Yosef Meystel Ttee
5% Or Greater Direct Ownership Interest · Organization
Devault, Diana
Operational/Managerial Control · Individual
Goldwater Care Management LLC
Operational/Managerial Control · Organization
Katzenstein, Meir
Operational/Managerial Control · Individual
Katzenstein, Meir
Corporate Officer · Individual
Mays, Erin
Operational/Managerial Control · Individual
Spector, Jennifer
Operational/Managerial Control · Individual
Spector, Jennifer
Corporate Officer · Individual
Turofsky, Steven
Operational/Managerial Control · Individual
Tversky, Aaron
Operational/Managerial Control · Individual
Tversky, Aaron
Corporate Officer · Individual
Wilhelm, Naftali
Operational/Managerial Control · Individual
Zafar, Muhammad
Operational/Managerial Control · Individual
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