Clearwater Nursing & Rehab: Medication Preference Ignored - KS
When he refused, nobody updated his care plan. When he complained, nobody forwarded it to the right people. When a certified medication aide arrived at his room on the morning of September 17, 2025, at 8:30 a.m. to give him his medications, he raised his voice and asked her how many times he had to say the same thing.
He said he could not take his medications on an empty stomach. He said he needed to take them half an hour to an hour after eating. He said he was tired of spending time in the bathroom.
The aide, identified in the report as CMA S, told him she would wait and took his vital signs instead. She confirmed to inspectors that R6 had told staff about this preference. She also confirmed that his electronic health record contained no guidance about giving him his medications with food.
Fifteen minutes later, a certified nursing aide brought him his breakfast tray.
The problem was not a single morning. R6 told inspectors he had repeated his request to staff so many times that it made him angry. He said he got tired of being sick. Eventually, he stopped taking his medications not because he wanted to refuse care, but because he could not take them without food and nobody had fixed the timing.
CMA R, who had also administered medications to R6, told inspectors she knew he had asked for his medications after eating or when he requested them. She said his medications were not ordered to be given with or after food, and left it there. No one had escalated the preference into a formal care plan change.
The social services staff member, identified as CMA/SSD X, said she was not aware of R6's concerns about medication timing at all. She told inspectors that residents should be interviewed on admission and routinely throughout their stay about their preferences, that concerns reported to staff should go to a supervisor, then to social services, then to the appropriate department. She confirmed R6's care plan had not been updated to reflect his preferences about meals and medications.
Dietary staff told inspectors that residents eating in their rooms received their trays approximately 30 to 45 minutes after the 8:00 a.m. dining room service. That gap, between when room-service residents ate and when medication rounds ran, was known. It was never addressed for R6.
Administrative Nurse D, interviewed on the afternoon of September 17, confirmed that residents should have the opportunity to participate in decisions about their care, including how and when their medications are given. She said preferences and refusals should be followed up on, care adjusted, dignity and independence promoted. Then she confirmed that R6's requests had not been communicated as expected and that the facility had not followed up as they should have.
The facility did not provide inspectors with any policy for accommodating resident preferences.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting a few residents. The citation was filed under F0558, which covers the right of residents to make choices about their care.
R6 knew he needed his medications. He said so. He kept taking them even when they made him sick, until the cycle wore him down enough that he stopped. He told staff. He told them again. He told them until he was raising his voice at 8:30 in the morning just to be heard.
His care plan still did not mention food.
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
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
CLEARWATER NURSING & REHABILITATION CENTER in CLEARWATER, KS was cited for violations during a health inspection on September 17, 2025.
When he refused, nobody updated his care plan.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.