Goldwater Care Clinton: No RN on Duty Nine Days - IL
Federal inspectors arrived at Goldwater Care Clinton on September 19, 2025, following a complaint. What they found in the facility's own nursing hall assignment sheets told most of the story before a single interview was conducted.
The sheets covered late August through mid-September. On nine separate days, August 27, August 28, September 2, September 3, September 4, September 9, September 11, September 13, and September 14, no registered nurse worked a consecutive eight-hour shift at the facility. That is the minimum required. Not a high bar. The floor beneath the floor.
At 2:30 in the afternoon on September 18, the facility's administrator, identified in the inspection report as V1, sat down with inspectors. The administrator confirmed there were days with no RN staffing available. Confirmed the current census was around 104 residents. Confirmed, in other words, everything the assignment sheets already showed.
The nine days did not form a single streak. They were scattered, which in some ways is worse. A facility in a genuine crisis, scrambling after a sudden departure, looks different from a facility where gaps appear, close, reappear, and close again across three weeks. The pattern in these records looks less like an emergency and more like a routine.
A registered nurse and a licensed practical nurse are not interchangeable in a nursing home, regardless of how staffing sheets get filled in on short days. An RN carries clinical responsibilities that cannot be delegated downward. Assessment, care plan decisions, the judgment calls that come at odd hours on a unit with more than a hundred people who are, by definition, there because they cannot fully care for themselves.
One hundred and four residents. The facility's bed management sheet, dated September 10, put the census at exactly that number. Inspectors noted the administrator described it as around the current census, meaning the building was running near capacity throughout the period in question.
The inspection was triggered by a complaint, not a routine survey cycle. That means someone, a resident, a family member, a staff member, decided something was wrong enough to report it. The assignment sheets that came out of that complaint covered nineteen days. Nine of them had no RN.
Inspectors tagged the deficiency under F0727, the federal standard requiring a registered nurse on duty for at least eight consecutive hours every day and a full-time RN serving as director of nursing. The level of harm was cited as minimal harm or potential for actual harm. That language reflects what inspectors could document, not necessarily what the nineteen days looked like from inside a room on the second floor at two in the morning.
The facility is located at 1 Park Lane West in Clinton, a city of roughly 7,000 people in DeWitt County, about 25 miles east of Bloomington. It operates under the Goldwater Care name.
What the inspection report does not contain is an explanation for why nine days happened instead of one, or two, or none. It does not contain a description of what care looked like on those shifts, who made clinical decisions, or whether anyone on those floors knew they were working without an RN available. The administrator confirmed the gaps existed. The record ends there.
The residents at Goldwater Care Clinton on August 27, on September 3, on September 13, did not choose to be in a facility that would go that day without a registered nurse. Most of them were there because they had no other option.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Clinton from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 17, 2026 · Our methodology
GOLDWATER CARE CLINTON in CLINTON, IL was cited for violations during a health inspection on September 19, 2025.
Federal inspectors arrived at Goldwater Care Clinton on September 19, 2025, following a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.