Goldwater Care Clinton
GOLDWATER CARE CLINTON in CLINTON, IL — inspection on May 28, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(injury/decline/room, etc.) that affect the resident.
missed administration of significant morning medications.
This failure affects eight of twelve
of 16.Findings include:R1, R2, R3, R4, R5, R6, R7, and R8's, Medication Administration Records dated May 1-31, 2026, do not document nurses' initials in the blank boxes, to indicate the R1, R2, R3, R4, R5, R6, R7, and R8's medications were administered on May 10, 2026, during morning medication administration.R1, R2, R3, R4, R5, R6, R7, and R8's Progress Notes do not document that family representatives were notified of the medication omission errors.On 5/21/26 at 11:10 am V23, R8's Power of Attorney said the facility did not notify V23 that R8 missed her medications on Mother's Day 5/10/26.On 5/21/26 at 1:55 pm V12, R1's Family Member stated she was not contacted by the facility to inform them that R1 missed her medications on 5/10/26.On 5/21/26 at 5:30 pm V20, R2's Family Member stated There has not been anyone call or tell me there were problems on Mother's Day (5/10/26) with my dad getting any of his medications.On 5/21/26 at 10:10 am V2, Interim Director of Nursing/Regional Nurse Consultant (DON) said that it is standard of practice that the family representatives be notified of medication errors. V2, DON said facility nurses, working the floor are expected to contact the families to inform them of the medication errors, and document the notification in the resident's medical record.The facility policy Physician-Family Notification- Change in Condition dated as revised 11/13/18 documents the following: Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner.
Responsibility: Licensed Nursing Personnel / Social Services Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
146076 05/28/2026
Goldwater Care Clinton 1 Park Lane West Clinton, IL 61727
significant medication errors were due nurse staffing issues, when the nurses on duty failed
worked 200 hall and the top of 300 hall, at 9:00 am and left sometime around 4:00 pm, and there was
was not a nurse on 100 hall on Mother's Day, therefore, R1 did not have her blood glucose level checked until later in the day.R1's Blood Sugar tracking sheet records R1's first blood glucose measurement on 5/10/26 was completed at 2:08 pm and measured 441, which required 12 units of insulin.On 5/22/26 at 11:45 am V13, Licensed Practical Nurse (LPN) stated she worked 400 hall on Mother's Day and stayed over until 9:00 pm.
There was no nurse on 100 hall. I had 30 residents of my own. On 5/22/26 at 12:15 pm V29, Agency Licensed Practical Nurse (LPN) said she worked the Memory Care unit on the opposite side of the building from the 100-hall unit. V29, LPN said there was no nurse on 100 hall day shift. A CNA called V29, LPN over to the 100 hall, when a resident (R2) to resident (R12) altercation took place in the 100-hall dining room. V29, LPN said she responded to the altercation and did an assessment.
While in the process of providing R2 and R12's care, V29 was called back to the Memory Care unit to assess R13 who had a fall. V29 also said that there was a nurse that came in and worked 9:00 am until about 4:00 pm on 200 hall and the top of 300 hall.
She left without saying a word, did not count narcotics at the end of her shift and left the medication cart keys on top of the medication carts. V29 also confirmed the medication keys were accessible to residents, staff and visitors at the center nurse's station.On 5/28/26 at 10:00 am V4, Licensed Practical Nurse/Minimum Data Set Coordinator stated she worked a partial shift on Mother's Day.
When she came in to work at 9:00 am V4 found the medication cart/narcotic box keys on the top of the 200 hall and 300 hall medication carts, and both med carts were parked at the center (corridor) nurses' station. V4 said there was not a nurse available to count narcotic medications when she came in to work nor when she left the facility. V4 stated she left the medication keys where she found them when she came in to work. V4 also stated she does not punch in electronically for her shift as an MDS Coordinator she just reports her time to V42, Human Resource Director.On 5/21/26 at 10:10 am V2, Interim Director of Nursing/Regional Nurse Consultant (DON) acknowledged the medication omission errors on 100 hall, Mother's Day 5/10/26, resulted from being short of licensed nurse staff.
The facilities CMS-802 Matrix dated 5/20/26 documents 103 residents reside in the facility.
146076 05/28/2026
Goldwater Care Clinton 1 Park Lane West Clinton, IL 61727
administration.On 5/20/26 at 3:30 pm R7, stated she missed the administration of medications and
hand.
Date Initiated: 06/23/2025.
Give analgesics as ordered by the physician.
Monitor and document
Date Initiated: 06/23/20258. R8's Physician Order Sheet dated May 1-31, 2026, documents the following medications orders:Aspirin 81 Oral Tablet Delayed Release, Give 1 tablet by mouth one time a day for antiplatelet related to Heart Failure Unspecified (and) Essential (Primary) Hypertension.Amlodipine Besylate Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for HTN (Hypertension) related to Essential (Primary) Hypertension.Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate), Give 1 tablet by mouth one time a day for HTN (Hypertension).Torsemide Oral Tablet 20 MG, Give 1 tablet by mouth one time a day for Edema related to Heart Failure Unspecified, and Essential (Primary) Hypertension.
The correlating MAR for May 2026 documents: Daily weight every day shift related to HEART FAILURE, UNSPECIFIED.
The 5/10/26 weight was not documented as completed.R8's Corresponding May 1-31, 2026, Medication Administration Record does not document nurses' initials in the blank boxes, to indicate the above medications were administered on May 10, 2026 during morning medication administration.On 5/27/26 at 10:05 am V30, Nurse Practitioner (NP) for V3, Medical Director (MD) stated Mother's Day I was off, (V3, MD) covers the weekend. On Monday, after Mother's Day, the Director of Nursing (V2) informed me that the residents didn't get the morning medication.
She specifically said that there were some residents on the one hall hundred hall (R1-R8 reside on the 100 hall).
Insulins, blood pressure medications, anticoagulants, and seizure medication in general, are all considered to be significant medication errors when not administered.
These residents (that reside on 100 hall) were monitored closely, once the errors were identified. To my knowledge, there was no negative outcome.On 5/21/26 at 10:10 am V2, Interim Director of Nursing/Regional Nurse Consultant (DON) acknowledged the above significant medication errors were made on Mother's Day 5/10/26, when residents did not receive their insulins and the other significant medication.V2, DON also stated V30 Nurse Practitioner (V3, Medical Director's Co- Provider) was notified Monday 5/11/26 and two additional primary care providers (V36 and V41 Physicians) were also notified of the 100 hall medication errors. V2, Director of Nursing (DON) provided an Electronic (Email-mail), undated, and signed by V2, DON which documents the following: Good evening! In transparency, I wanted to let (V41, Physician) and (V36, Physician) know that we experienced an issue with nurse coverage on Sunday, May 10th for the 6a to 6p shift. At this time when nursing coverage was being obtained, specific residents missed their 8am medications. We did obtain coverage, however, the 8am medications were not able to be administered within the appropriate time frame. I am working on which specific residents and their medications that were not administered for the 8am medication pass. I will send over once completed tomorrow morning. I did not see physician notification in residents' charts as I am auditing. I apologize for the lack of communication. I just returned from vacation. It is a priority to complete the audit and provide the physicians with a full report on their patients. We are working diligently to improve the clinical department.
Please let me know if you have any questions or issues. I take your feedback seriously and am committed to building a great relationship with the clinical team and physicians.The facility policy Preparation and General Guidelines dated November 2021 documents the following: MEDICATION ADMINISTRATION-GENERAL GUIDELINES - PolicyMedications are administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so.
Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration).
The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.
146076 05/28/2026
Goldwater Care Clinton 1 Park Lane West Clinton, IL 61727
their specific log sheet.2.
Obtain sign-out records/logs and keys to the controlled storage
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.