F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation, interview, and record review the facility failed to ensure resident room temperatures
were maintained at a safe and comfortable temperature of 71 degrees Fahrenheit or higher for 14 of 15
residents (R2-R15) reviewed for safe and comfortable environment in the sample of 17.
Findings include:
The facility's Maintenance Policy (undated) documents, Purpose: To ensure the building (interior and
exterior), grounds, and equipment are maintained in a safe and operatable manner. Policy: It is the policy of
the facility to provide a safe, accessible, effective environment of care that is consistent with its mission,
services, and laws and regulations.
The facility's Code White-Extreme Weather dated 9-22-22 documents, Purpose: To provide staff specific
guidance and instruction on how to initiate an emergency code and steps to be taken to ensure the safety
of residents and staff in the event of extreme weather/temperature related conditions. The facility will follow
federal requirement to maintain facility temperatures between 71-80 degrees Fahrenheit.
The Local AccuWeather website documents the weather for Peoria Heights Illinois was a high of 30
degrees F (Fahrenheit) and a low of 16 degrees F on Sunday 12-1-24, a high of 25 degrees F and a low of
14 degrees F on Monday 12-2-24, and a high of 27 degrees F and a low of 24 degrees on Tuesday
12-3-24.
On 12-3-24 from 9:45 AM through 10:15 AM a tour of the facility was conducted with V2 (Director of
Nursing). During this timeframe V2 obtained resident room temperatures by using an infrared temperature
gun that was pointed at the highest point of the residents' walls. R2's room was 67 degrees F, R3 and R4's
room was 63 degrees F, R5's room was 60 degrees F, R6's room was 63.3 degrees F, R7's room was 64.2
degrees F, R8's room was 55.8 degrees F, R9's room was 55 degrees F, R10 and R11's room was 59
degrees F, R14's room was 64 degrees F, R13's room was 66 degrees F, and R14 and R15's room was 60
degrees F. All heaters in R2-R15's rooms were not working during this timeframe.
On 12-3-24 at 9:45 AM R2 stated, It's cold in here.
On 12-3-24 at 9:55 AM both R3 and R4 were sitting in bed in their rooms with two top covers on. R3 stated,
It has been cold all day.
On 12-3-24 at 10:00 AM R5 was lying in bed in her room with a stocking cap on. R5 stated, It feels like it is
40 degrees in here. It has been really cold in here for the last couple days. My heat has
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145239
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145239
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldwater Care Peoria Heights
5533 North Galena Road
Peoria Heights, IL 61614
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
not been working.
Level of Harm - Minimal harm
or potential for actual harm
On 12-3-24 at 10:05 AM R6 stated, I am cold.
Residents Affected - Some
On 12-3-24 at 10:07 AM R7 was lying in bed with two blankets. R7 stated, I have not had heat in my room
for two days. It has been really cold.
On 12-3-24 at 10:09 AM R8 stated, It is cold. I feel like there is a windmill blowing on me.
On 12-3-24 at 10:12 AM R9 stated, The heat has been off for a couple days. The staff are saying the heat is
not working. It has been cold.
On 12-3-24 at 10:15 AM R11 stated, I have been cold for a few days.
On 12-3-24 at 10:17 AM R12 was sitting in her bed with a stocking cap, gloves, and a coat on. R12 stated, I
wish they would get some heat on and working around here. I am cold.
On 12-3-24 at 10:20 AM both R14 and R15 both confirmed their heater has not worked for at least a day
and their room has been cold.
On 12-3-24 at 10:30 AM V2 confirmed that R2-R15's room heaters were run from a boiler and their heaters
had not been working since sometime the day before (12-2-24).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145239
If continuation sheet
Page 2 of 2
