Clearwater Nursing & Rehab: Sexual Abuse, Immediate Jeopardy - KS
Federal inspectors who arrived at the facility on September 17, 2025 found conditions serious enough to declare immediate jeopardy, the most severe finding available under federal nursing home oversight. The residents at the center of the abuse findings, identified in inspection records as R2, R3, and R4, were cognitively impaired. Inspectors noted they were unable to effectively communicate the impact of what they had experienced.
That incapacity did not reduce the severity of the finding. Inspectors applied what is known in federal oversight as the "reasonable person concept," a standard that asks what a reasonable person would experience in the same circumstances, and rated the harm as actual psychosocial harm. The scope and severity of the violation was recorded at a G, a level that reflects real harm to real people, not just the risk of it.
A fourth resident, identified as R1, was at the center of a separate and intertwined set of failures. R1 had been placed on one-to-one monitoring, meaning a staff member was supposed to be with him at all times. The inspection record does not describe what R1 did, but the corrective actions taken on the day inspectors arrived reveal the shape of it: all staff were educated that same afternoon about R1's specific behaviors that indicate he might be escalating, and what to do in response. His Depo-Provera injections, a medication used to chemically suppress testosterone and is sometimes prescribed to manage sexual behavior in institutional settings, had not been reliably administered. The Director of Nursing added the injection schedule to her personal calendar on September 17 as a reminder to ensure the medication was on hand every two weeks.
The inspection record does not say how long R1 had been at the facility, how long the Depo-Provera had been prescribed, or how many doses had been missed. It does not say how long R2, R3, and R4 had been residents. It does not say whether any of the abuse had been reported to law enforcement, or whether any staff member had been terminated before the day inspectors walked in.
What the record does say is that the facility had recently changed both its Administrator and its Director of Nursing. Both new leaders received training on September 17, 2025, the same day inspectors were on-site, on how to conduct a root cause analysis when a resident is placed on one-to-one monitoring. That training covered what led up to an incident, what behaviors preceded it, and what to look for after a resident was removed from one-to-one oversight. The entire interdisciplinary team received the same in-service that afternoon.
The timing is difficult to read as anything other than a response to the inspection itself.
Before September 17, the facility had no policy requiring ongoing monitoring of residents once they were removed from one-to-one oversight. That gap was closed the same day inspectors arrived, when the facility and its corporate entity modified the existing one-to-one policy to require continued monitoring after the intensive supervision ended, with regional support brought in to track whether the interventions were working.
A Quality Assurance and Performance Improvement meeting was held that afternoon as well.
At 5:05 in the evening, surveyors verified that the corrective actions had been implemented. The immediate jeopardy was addressed, at least on paper, within the span of a single inspection day.
The staff member whose conduct triggered the one-to-one monitoring of R1, or whose conduct was connected to the abuse of R2, R3, and R4, is not named in the publicly available portion of the inspection record. What the record does note is that one staff member was removed from work pending verification of in-service training completion. Whether that person was an aide, a nurse, or someone in a supervisory role is not stated.
R1 was being transferred. The facility accepted him into another placement, with a discharge date set for November 1, 2025, or sooner.
For R2, R3, and R4, the inspection record says nothing about what happens next. It does not describe their conditions, their length of stay, or whether they have family members who were notified. It records, with bureaucratic flatness, that they were cognitively impaired and unable to effectively communicate the impact of the physical and sexual abuse they experienced.
That sentence, tucked into the explanation of why inspectors used the reasonable person standard rather than resident self-report, is the fullest account the public record offers of what those three people went through.
Clearwater Nursing & Rehabilitation Center sits on East Wood Street in Clearwater, a small city in south-central Kansas. The facility's inspection history and ownership structure were not detailed in the complaint inspection report released for this finding.
What the report makes clear is that when inspectors arrived, the facility's two most senior clinical and administrative leaders were new enough that they had not yet been trained on one of the most basic protocols in nursing home safety: what to do when a resident is dangerous enough to require someone watching them every hour of every day, and what to do when that watch is lifted.
The residents who could not speak for themselves had no one filling that gap.
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 27, 2026 · Our methodology
CLEARWATER NURSING & REHABILITATION CENTER in CLEARWATER, KS was cited for abuse-related violations during a health inspection on September 17, 2025.
The residents at the center of the abuse findings, identified in inspection records as R2, R3, and R4, were cognitively impaired.
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.