Clearwater Nursing & Rehab: Infection Control Failures - KS
Federal inspectors documented the June 1 incident at Clearwater Nursing & Rehabilitation Center in a report that also found a resident's breathing treatment mask and tubing lying uncovered on the floor for more than 22 hours.
The incontinence care observation began at 10:00 AM. Resident 42 was resting in bed when two certified nursing aides, identified in the report as CNA N and CNA O, entered the room in gowns and gloves. The resident told them he'd had a bowel movement and needed care.
CNA O gathered supplies. CNA N pulled down the resident's pants and positioned him on his left side, then pulled back the brief to reveal a moderate amount of stool covering his backside and a wound dressing. CNA N removed the brief and the dressing, cleaned the back peri area, then had the resident roll onto his back.
At that point CNA O stepped in — still wearing the same gloves that had been in contact with the stool — and cleaned the resident's front peri area. Then, wearing those same gloves, CNA O placed a new incontinence brief beneath the resident and fastened it.
The aides discarded those gloves, put on fresh ones to help pull up the resident's pants, removed their gowns, bagged everything, and left. Neither washed their hands. Neither used hand sanitizer.
Twenty minutes later, at 10:20 AM, CNA N confirmed what inspectors had observed. She acknowledged she had not changed gloves or washed her hands after the soiled portion of the care. She told inspectors she usually washes her hands when she enters another resident's room.
The facility's own hand hygiene policy, though undated, listed hand-washing as required before moving from a contaminated body site to a clean body site during resident care, and after removing gloves. The administrative nurse told inspectors the following morning that she would expect staff to change gloves between the dirty portion of incontinence care and placing a new brief, and to wash their hands before and after providing care.
What she expected and what happened were not the same thing.
The second finding involved Resident 12, who uses a breathing treatment machine. On June 2 at 10:14 AM, inspectors found the resident's mask and tubing lying on the floor beside a recliner, resting on top of a cloth bag, completely uncovered. A licensed nurse, identified as LN G, confirmed what she was looking at and asked the resident where the plastic storage bag was. The resident didn't answer.
LN G moved the mask from the floor to a nearby end table, told inspectors she would get a bag and take care of it, and left the room. The facility's oxygen policy instructs staff to store breathing equipment in a dated plastic bag at the bedside.
The next morning — at 8:51 AM on June 3, more than 22 hours after inspectors first observed the mask on the floor — the administrative nurse was still discussing what should have been done.
The inspection, completed June 3, 2026, tagged both findings at a level of minimal harm with potential for actual harm, affecting a small number of residents. CMS assigned the event identification number 175454.
Clearwater Nursing & Rehabilitation Center sits at 620 East Wood Street. For Resident 42, whose incontinence care included an open wound site already being dressed by staff, the question the report leaves unanswered is what got into that wound.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clearwater Nursing & Rehabilitation Center from 2026-06-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CLEARWATER NURSING & REHABILITATION CENTER in CLEARWATER, KS was cited for violations during a health inspection on June 3, 2026.
The incontinence care observation began at 10:00 AM.
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.