Clearwater Nursing & Rehab: Abuse Probe Failures - KS
That incident was one of two separate resident-to-resident abuse episodes at Clearwater this summer. Both went uninvestigated, at least in any documented form that the facility could produce when federal inspectors arrived on September 17.
The first happened in the dining room at 3:08 in the morning on June 21. A staff member walked in and found two residents, identified in inspection records as Resident 1 and Resident 2, slapping each other on the arms. Resident 1 grabbed the female resident's arm. Staff intervened and separated them. The facility filed an initial report with the Kansas State Agency, as required. That was apparently where the paperwork stopped.
Seven days later, on June 28, at just after 11 in the morning, staff observed Resident 1 touching a different female resident, Resident 3, in the genital area. Staff notified Resident 1's representative. According to a progress note recorded that day, the representative's response was that they did not know how staff would stop Resident 1 from doing that.
The facility filed another initial report with the state. And again, the investigation went nowhere anyone could find.
By the time inspectors arrived in September, the facility could not produce a completed investigation for either incident. It could not provide evidence that any completed investigation had been submitted to the State Agency within five working days of either event, as its own written policy requires. The policy, dated May 2025, states clearly that the administrator or a designee will provide appropriate agencies with a written report of investigation findings within five working days of an incident's occurrence.
The facility had the policy. It did not have the investigations.
Administrative Staff A, interviewed by inspectors on the morning of the inspection, said he expected all reportable incidents to be thoroughly investigated and the completed findings submitted within the required timeframe. Then he acknowledged he could not provide those investigations. He explained that he had not been working at the facility during the June incidents and was not sure whether anything had ever been submitted to the state or when.
That explanation raises a question the inspection report does not answer: if the administrator who was in place during June knew these incidents had occurred and knew that state reporting was required, what happened to that paperwork? The current administrator could not say. The state agency, apparently, did not have it either, or the deficiency would not have been cited.
What the facility did have, for the June 28 incident, was a progress note documenting something serious. A staff member had observed a resident committing what amounts to sexual abuse against another resident. The note recorded that going forward, Resident 1 would be monitored on a one-to-one basis. One-to-one monitoring is a significant intervention, the kind of response that signals staff understood the severity of what had happened. The investigation that should have followed, the formal written accounting of what occurred, who was involved, what protective steps were taken, and what the findings were, never materialized in any form the facility could hand to inspectors three months later.
The June 21 incident was less severe in its physical description. Two residents struck each other on the arms. Staff separated them quickly. But resident-to-resident physical altercations, even those that appear minor, carry reporting requirements precisely because patterns matter. A facility tracking these incidents properly would know whether Resident 1 had a history of aggression toward other residents, whether the same pairing had caused problems before, whether the one-to-one monitoring ordered after June 28 should have begun earlier. Without completed investigations, none of that institutional knowledge exists in any form that regulators or incoming staff could access.
Clearwater Nursing & Rehabilitation Center reported a census of 47 residents at the time of the inspection. Inspectors reviewed records for six residents specifically flagged for abuse-related concerns. The deficiency was tagged at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale, and described as affecting few residents. That classification reflects the regulatory framing of the paperwork failure itself, not the underlying incidents. The sexual contact on June 28 is described in the progress note without any modifier suggesting it was minor.
The inspection was a complaint survey, meaning someone, a resident, a family member, a staff member, or another party with knowledge of the facility, contacted authorities before inspectors arrived. The report does not identify who filed the complaint or what it alleged. It is not possible to know from the public record whether the complaint was directly related to these two incidents or something else entirely. What is clear is that when inspectors came looking, the facility had no completed abuse investigations to show them for either June event.
Abuse reporting requirements in nursing homes exist for reasons that go beyond paperwork compliance. When a facility submits a completed investigation to a state agency, that agency can review whether the facility's response was adequate, whether the resident who was harmed received appropriate follow-up care, whether the resident who caused harm was appropriately supervised or assessed, and whether similar incidents had occurred elsewhere in the facility or involved the same individuals. When those investigations are never submitted, the state cannot perform that review. The oversight mechanism breaks down entirely.
Resident 1's representative, as recorded in the June 28 progress note, expressed what sounded like resignation. They did not know how staff would stop Resident 1 from touching other residents. Whether that representative was ever contacted again as part of a formal investigation, whether Resident 1 received any assessment or intervention beyond the one-to-one monitoring order, whether the female resident who was touched received any follow-up care or was even informed of her rights, none of that appears in what the facility was able to produce.
The administrator on duty in September inherited whatever was or was not done in June. He told inspectors he wasn't there. The people who were there left no finished record behind.
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.
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 23, 2026 · Our methodology
CLEARWATER NURSING & REHABILITATION CENTER in CLEARWATER, KS was cited for abuse-related violations during a health inspection on September 17, 2025.
That incident was one of two separate resident-to-resident abuse episodes at Clearwater this summer.
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.