Clearwater Nursing & Rehabilitation Center could not provide federal inspectors with completed investigations for either incident involving the same male resident in late June. State regulations require nursing homes to submit finished investigations to state authorities within five working days of any reported abuse.
The first incident occurred on June 21 at 3:08 AM when staff witnessed the male resident and a female resident "slapping each other on the arms" in the dining room. Staff documented that the male resident "grabbed the female resident's arm" before staff intervened and separated them.
One week later, on June 28 at 11:03 AM, staff observed the same male resident "touching a female resident in the genital area." Staff immediately notified the resident's representative and placed him on one-to-one monitoring.
The representative's response highlighted the facility's challenge in preventing future incidents. According to progress notes, the representative "stated they did not know how staff would stop" the male resident from inappropriate touching.
Both incidents were reported to state authorities through the facility's incident reporting system. The June 21 altercation was assigned incident number KS00196132, while the June 28 inappropriate touching received incident number KS00196270.
But when federal inspectors arrived in September to investigate a complaint, the facility could not produce the completed investigations for either incident.
Administrative Staff A, interviewed on September 17 at 10:25 AM, acknowledged the facility's failure. He told inspectors he "expected all reportable incidents to be thoroughly investigated and the completed investigation to be submitted in the time frame allowable."
However, the administrator admitted he "was unable to provide the completed investigations." He explained he wasn't working at the facility during the June incidents and "was not sure if anything was submitted" to state authorities "or when."
The facility's own policy, updated in May 2025, explicitly requires the administrator or designee to "provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident."
The nursing home houses 47 residents according to its reported census. Federal inspectors reviewed records for 10 residents during their September visit, with six residents specifically examined for potential abuse issues.
The inspection focused on the facility's compliance with federal requirements to report suspected abuse, neglect, or theft and provide investigation results to proper authorities in a timely manner.
Resident-to-resident incidents pose particular challenges for nursing homes, especially when they involve residents with cognitive impairments who may not understand the consequences of their actions. The male resident's pattern of physical and sexual contact with female residents within a week suggests underlying behavioral issues that required immediate intervention and ongoing monitoring.
The facility's inability to produce completed investigations three months after the incidents raises questions about its internal reporting and documentation systems. Federal regulations require nursing homes to maintain detailed records of all incidents and their investigations to demonstrate they are taking appropriate steps to protect residents from harm.
The June incidents involved three different residents, with the male resident as the common factor in both altercations. The first incident appeared to involve mutual physical contact, with both residents slapping each other before staff separated them. The second incident was more serious, involving unwanted sexual contact that prompted immediate one-to-one supervision.
Staff response to the inappropriate touching incident showed awareness of the severity. They immediately contacted the resident's representative and implemented enhanced monitoring. However, the representative's admission that they didn't know how to prevent future incidents suggests the facility faced ongoing challenges in managing the resident's behavior.
The facility reported both incidents to state authorities through proper channels, indicating staff understood their reporting obligations. However, the missing completed investigations suggest a breakdown in the follow-up process required to document findings and corrective actions.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. This designation indicates the incidents were contained and didn't result in serious physical injuries, though the psychological impact on the female residents involved was not detailed in inspection records.
The September inspection occurred in response to a complaint, though the specific nature of the complaint that triggered the federal review was not disclosed in available records. The facility's census of 47 residents places it in the small-to-medium category for nursing homes, where staffing and administrative oversight can be particularly challenging.
Administrative Staff A's acknowledgment that he wasn't present during the June incidents highlights potential continuity issues in facility leadership. His inability to confirm whether investigations were ever completed or submitted suggests gaps in administrative handover procedures when leadership changes occur.
The facility's Abuse Prevention Program policy, dated May 2025, was relatively recent at the time of the June incidents. This timing raises questions about whether staff were fully trained on new procedures or if the policy update was implemented in response to earlier problems.
The five-working-day deadline for completed investigations serves an important protective function, ensuring facilities don't delay addressing safety concerns while evidence and witness memories remain fresh. The missing investigations mean state authorities lacked crucial information about what caused the incidents and what steps were taken to prevent recurrence.
The male resident's escalation from physical altercation to sexual touching within a week demonstrates how quickly situations can deteriorate in nursing home settings. The facility's response of implementing one-to-one monitoring after the second incident suggests recognition of the increased risk, but the lack of completed investigations left gaps in understanding the root causes.
Three months after the incidents, the facility still could not produce evidence that required investigations were ever completed or submitted to state authorities, leaving regulators without crucial documentation about resident safety measures and corrective actions taken to prevent future abuse.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clearwater Nursing & Rehabilitation Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Clearwater Nursing & Rehabilitation Center
- Browse all KS nursing home inspections