Latest reports, citations, and penalties from CMS data
Inspectors classified the deficiency as isolated, meaning it did not appear to be a pattern running through every unit or shift....
That same morning, inspectors were working through what a three-day stretch of staffing records actually showed....
By 2:50 AM, the nurse had called the Director of Nursing....
On each of those days, meal intake was either missing from the record entirely or the notes contained no explanation for why the resident hadn't eaten....
She needed a walker and a manual wheelchair and required maximum assistance to transfer from one surface to another....
The plan said ten licensed practical nurses were needed to cover a full 24-hour period....
That is what inspectors found when they reviewed records at College Pines Health and Rehabilitation on 95 Locust Street during an April 2026 survey....
The resident, identified in inspection records as R101, was admitted with a foam dressing ordered as a preventative measure....
The inspection report does not identify which resident was affected, what the suspected incident involved, or who was alleged to have done what to whom....
Inspectors reviewed facility incident reports, medical records, and interviewed residents directly....
The facility's written process called for a Behavior Management team to convene when a resident showed new or worsening behaviors....
The resident, identified only as R5 in federal inspection records, had moderate cognitive impairment and needed substantial help getting to the toilet....
The resident, identified in inspection records only as Resident #2, has moderate cognitive impairment and is fully dependent on staff for toileting hygiene....
Federal inspectors arrived on April 27, 2026....
Not a word about cleaning them....
R6's diagnoses filled the page....
Inspectors cited the facility on April 29, 2026, after finding that Resident B, admitted earlier that month, had no baseline care plan in place....
What inspectors found was not a complicated case....
Federal inspectors visited Goldwater Care Clinton on April 29, 2026, following a complaint....
The certified nursing aide, identified in inspection records as V4, looked at the daily schedule for January 27 and confirmed her own name was on it....