Goldwater Care Clinton

In the surveyor’s words

From the most serious findings on record at Goldwater Care Clinton, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610Jun 7, 2021

  Based on interview and record review the facility failed to protect residents from abuse by: failing to recognize an allegation of sexual abuse between staff and a resident, failed to initiate an investigation into the allegation of sexual abuse and failed to remove the alleged perpetrator from continued direct care of a resident for one five residents (R4) reviewed for abuse on the sample list of five. This failure resulted in the V15 Certified Nursing Assistant (alleged perpetrator) continuing to provide personal cares for R4 for 24 shifts with no determination if sexual abuse of R4 by V15 had occurred. This failure also had the potential to affect all 75 residents residing in the facility as V15 continued to work having access to all residents at the facility. […]

• Immediate jeopardy, isolatedF689Aug 20, 2026

  Based on observation, interview, and record review the facility failed to supervise/monitor three residents (R7,R8,R9) with exit seeking behaviors and failed establish a care plan and initiate interventions for elopement to prevent a cognitively impaired resident from exiting the facility unnoticed. These failures resulted in R7 leaving the facility without staff supervision or knowledge for an undetermined period on the night of 7/5/26. R7 was found by staff at approximately 2:50AM on 7/6/26 lying in the parking lot a few feet from a deep drainage ditch. R7 sustained a sprained ankle with swelling, bruising, and pain. […]

• Immediate jeopardy, isolatedF684Feb 8, 2023

  Based on interview and record review the facility failed to follow facility policy regarding emergency care for falls, resulting in a delay in assessment, physician notification and treatment for a resident. This failure resulted in R200 experiencing unrelieved excruciating pain for approximately 20 hours from a fracture sustained from an earlier fall. R200 had a Markedly Displaced Comminuted and Angulated Intertrochanteric Fracture of the left femur for 24 hours without evaluation/treatment. This failure affects one (R200) of five residents reviewed for falls in the sample of 37. […]

• Immediate jeopardy, isolatedF600Jun 7, 2021

  Based on interview and record review the facility failed to ensure a resident was free from abuse by staff. Staff witnessed a Certified Nurse's Assistant (CNA) V15 inappropriately interacting with a resident (R4). The facility continued to schedule V15 to provide personal care of R4 on numerous occasions following the abuse incident. This failure affects one of three residents (R4) reviewed for abuse in the sample of five residents. These failures resulted in an immediate jeopardy. […]

• Actual harm, isolatedF760Jul 17, 2026

  Based on interview and record review the facility failed to ensure medications were administered as ordered to the correct resident for one of one resident (R3) reviewed for significant medication errors in the sample list of 23. This failure resulted in R3's blood pressure dropping to 60/30, feeling ill and being sent to the emergency room for evaluation and cardiac monitoring. Findings include: R3's Care Plan dated 3/17/2026 documents R3 diagnoses including Coronary Artery Bypass Grafts, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus and Congestive Heart Failure. This Care Plan further documents an admission date of 09/24/2025.R3's Care Plan dated 11/26/2025 documents R3 is at risk for seizures. […]