Goldwater Care Clinton: Medication Failures on Mother's Day - IL
One resident, identified in the inspection report as R7, told inspectors on May 20 that she missed her medications and "hurt all over." Her care plan documented osteoarthritis of the left hand, with orders to give analgesics as prescribed and monitor for effectiveness. Whether she received them that morning, the record did not show.
Another resident, R8, was managing heart failure and hypertension with four daily medications: aspirin, amlodipine, metoprolol, and torsemide. The May medication record showed blank boxes for the morning pass on May 10. No nurse's initials. No documentation that the medications were given. A daily weight required for heart failure monitoring also went unrecorded that day.
The facility's interim Director of Nursing, who had just returned from vacation, sent an undated email to two physicians that evening. "I am working on which specific residents and their medications that were not administered for the 8am medication pass," she wrote. "I will send over once completed tomorrow morning." She added that she had not found physician notification in the residents' charts and apologized for "the lack of communication."
The nurse practitioner covering for the medical director told inspectors she learned about the missed medications the Monday after Mother's Day, when the Director of Nursing informed her. "Insulins, blood pressure medications, anticoagulants, and seizure medication in general, are all considered to be significant medication errors when not administered," the nurse practitioner said. She added that residents on the 100 hall were monitored closely once the errors were identified and that, to her knowledge, there was no negative outcome.
The interim Director of Nursing confirmed the errors to inspectors on May 21, acknowledging that the morning shift on May 10 had not been covered in time to complete the medication pass.
R7 said she hurt all over. The inspection report does not say whether anyone followed up with her directly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Clinton from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 21, 2026 · Our methodology
GOLDWATER CARE CLINTON in CLINTON, IL was cited for violations during a health inspection on May 28, 2026.
Whether she received them that morning, the record did not show.
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.