Goldwater Care Clinton
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 7 Google reviews

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (43 vs median 11.0)
- High staff turnover (77%)
- High RN turnover (77%)
Bottom 25% in IL · Critically understaffed (RN) · Above average staffing · Very high staff turnover · Worst in GOLDWATER CARE chain · $54,678 in fines · Abuse citation
What this means for your family
While the facility is praised for its physical cleanliness and welcoming environment, the recent report regarding failure to follow doctor's orders and lack of supervision for high-risk residents is a major red flag. Families should conduct a thorough audit of the care plan and billing processes before admission to ensure resident safety and administrative transparency.
Google Reviews
Google Reviews
7 reviews on Google“Goldwater Care Clinton receives polarized feedback, with several reviewers praising the facility's cleanliness and the staff's positive attitude. However, a serious report highlights critical failures in following medical care plans, improper billing practices, and dangerous lapses in supervision for residents with swallowing hazards.”
Quality Themes
Tap a score for detailsStrengths
- Exceptionally clean facility
- Welcoming and positive staff environment
- Home-like, cozy atmosphere
Concerns
- Inadequate supervision of residents with choking hazards
- Reliance on agency staff who do not know residents
- Billing errors and improper billing practices
Rating Trends
Tap a year to see what changed
Distribution · 7 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1Given the facility's reliance on agency staff, what specific steps are taken to ensure that temporary team members are fully briefed on my loved one's unique care needs and preferences?
- 2I understand that medication management is a high priority; could you walk me through your current process for ensuring accuracy and timely administration for residents?
- 3With the recent focus on dining experiences, what improvements are being made to the food quality and the overall atmosphere in the dining room?
- 4How do you ensure consistent supervision and safety protocols for residents who may have specific dietary or choking risks during mealtimes?
- 5What is your standard procedure for keeping families updated on their loved one's health status, and who is the primary point of contact for resolving billing or administrative questions?
- 6Since the facility is known for its cozy, home-like atmosphere, what kind of daily activities or social programs are currently in place to help residents feel engaged and part of the community?
Personalized based on this facility's data
Key Review Excerpts
“Never should a “mechanical diet, choking hazard” resident be left a tray in their room, with no staff supervision.”
“The facility is truly one of the cleanest I have ever seen, and our families are absolutely wonderful.”
“The staff did not follow the care plan/dr orders. They do not bill correctly, & try to bill “ friends/contacts” with no legal authority to patients bills, rather than bill insurance correctly.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
4
measures
10
measures
3
measures
Residents vaccinated for pneumonia
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents needing more daily help over time
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility shows a concerning pattern of complaint-triggered violations with families filing 54 complaints leading to federal deficiencies. The most recurring problems involve medication management, safety supervision to prevent accidents, and protection from abuse and neglect. Issues with appropriate treatment and care planning also persist across multiple surveys, indicating ongoing quality challenges that have not been fully resolved despite correction plans.
Apr 29, 2026Complaint3
Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Apr 15, 2026Complaint3
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Mar 21, 2026Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Feb 18, 2026Routine23
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Feb 18, 2026Complaint3
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Jan 13, 2026Complaint11
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Federal Penalties
Fine
Jan 13, 2026
$253,800
Payment Denial
Jan 13, 2026
79-day denial
Fine
Dec 5, 2024
$32,744
Ownership & Operations
Who Operates This Facility
Goldwater Care Clinton
nonprofit
Chain Affiliation
Goldwater Care
11 facilities nationwide
Chain avg rating: 1.4/5 · Rank 8 of 11 (Worst)
Ownership & Management
Owners
Berkowitz, David
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Meystel, Yosef
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Key personnel
Contact
Get in Touch
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References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
7 reviews from families & visitors
Official Website
Visit goldwatercare.com
Medicare data downloads
Original nursing home datasets
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