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Nursing HomeMedicaid Investigative

Goldwater Care Clinton

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

1 Park Lane West, Clinton, IL 61727134 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.4/5

based on 7 Google reviews

5
4
3
2
1
Goldwater Care Clinton Nursing Home in Clinton, IL — Street View
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8/ 10
critical Risk

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

Source: Medicare data

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 details
Food0.0Staff5.0Clean10.0ActivitiesN/AMeds1.0MemoryN/AComms2.0Value1.0

Strengths

  • 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

2345.02025(5)3.02026(2)

Distribution · 7 analyzed

5
6
4
0
3
0
2
0
1
1

How They Respond to Reviews

0%response rate

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.

Family member · 2026☆☆☆☆

The facility is truly one of the cleanest I have ever seen, and our families are absolutely wonderful.

Family member · 2025★★★★★

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.

Family member · 2026☆☆☆☆
Source: 7 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.19hrs
25%
Registered nurses for medical care
Total Nursing
3.36hrs
82%
All nurses + aides combined
Staff Turnover
73%
Lower is better (< 30% = good)
RN Turnover
60%
Lower is better (< 30% = good)

Both 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

Medicare Rating
2/ 5
Better Than Avg

4

measures

Worse Than Avg

10

measures

Mixed Results

3

measures

Long-Stay Residents
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility43.0%
Worse than Avg
Here
43.0%
US
93.4%
IL
90.0%
😔

Residents with depression symptoms

↓ Lower is better
This Facility47.8%
Mixed vs Avgs
Here
47.8%
US
12.1%
IL
52.5%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility34.2%
Worse than Avg
Here
34.2%
US
15.3%
IL
15.9%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility33.6%
Worse than Avg
Here
33.6%
US
15.5%
IL
21.8%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility30.1%
Worse than Avg
Here
30.1%
US
19.5%
IL
18.3%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility24.5%
Worse than Avg
Here
24.5%
US
14.4%
IL
14.2%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility15.7%
Worse than Avg
Here
15.7%
US
81.8%
IL
69.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility27.9%
Worse than Avg
Here
27.9%
US
79.8%
IL
63.1%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.3%
Mixed vs Avgs
Here
2.3%
US
1.6%
IL
2.4%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

51deficiencies
3penalties
Well above state avg (12.0)
64 complaint-triggered
$54,678 in fines

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, 2026Complaint
3
0727Potential for harm · WidespreadCorrected

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.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Apr 15, 2026Complaint
3
0578Potential for harm · IsolatedCorrected

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.

0600Potential for harm · IsolatedCorrected

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Mar 21, 2026Complaint
3
0600Potential for harm · IsolatedCorrected

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.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Feb 18, 2026Routine
23
0730Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0868Potential for harm · WidespreadCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0882Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

0944Potential for harm · WidespreadCorrected

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

0949Potential for harm · WidespreadCorrected

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

0741Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0561Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0761Potential for harm · PatternCorrected

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.

0883Potential for harm · PatternCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0887Potential for harm · PatternCorrected

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.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0580Potential for harm · IsolatedCorrected

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.

0605Potential for harm · IsolatedCorrected

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.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

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.

0657Potential for harm · IsolatedCorrected

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0805Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Feb 18, 2026Complaint
3
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0760Actual harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0727Potential for harm · WidespreadCorrected

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, 2026Complaint
11
0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0697Actual harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0727Potential for harm · WidespreadCorrected

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.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0760Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0580Potential for harm · IsolatedCorrected

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.

0609Potential for harm · IsolatedCorrected

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

Owner / Operator

Goldwater Care Clinton

Organization Type

nonprofit

Chain Affiliation

Chain Name

Goldwater Care

Chain Size

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

Rissman, RyanManaging Control - Governing BodyStachowiak, MelissaManaging Control - Governing BodySpector, JenniferOfficer / DirectorGoldwater Care Management LLCManagerBanks, ChristineManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

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