Clearwater Nursing & Rehabilitation Center

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

listen to his requests, and he had to tell the staff over and over. Resident R6 stated again that this made him angry. Resident R6 stated he got tired of being sick in the bathroom and said he could not take his medications on an empty stomach, so he would just not take them. He stated he did not usually refuse his medications because he knew he needed them, but he could not take them unless he had eaten prior to taking them, so that is when

he would refuse to take his medications.On 09/17/25 at 08:30 AM, CMA S entered the resident's room and informed the resident that she needed to check his vital signs and that she was giving him his medications. Resident R6 replied in a loud voice that he would only tell them one more time that he could not take his medications because he had not eaten yet, and it would make him sick. He stated he needed to take his medication one-half hour to an hour after he ate to keep from being sick. Resident R6 then asked CMA S how many times he had to tell them the same thing. He stated he was tired of having to spend time in the bathroom because he took his medications on an empty stomach. CMA S stated she would wait to give him his medications, but would take his vital signs to make sure his blood pressure was within range to give him his blood pressure medications. CMA S confirmed Resident R6 had informed staff he would not take his medications unless he had eaten and confirmed Resident R6's EHR lacked guidance to give Resident R6 his medications with food, as he preferred. CMA S stated she informed the nurse when the resident refused his medications.On 09/17/25 at 08:45 AM, Certified Nurse Aide (CNA) M entered the resident's room and asked the resident if he wanted breakfast.

The resident said yes, he had to eat before he could take his medications. CNA M left the room and then returned with the resident's breakfast tray. On 09/16/25 at 12:15 PM, Certified Medication Aide (CMA)/Social Service Staff (SSD) X stated the facility worked on Resident R6's discharge plan back to the community, but his multiple transfers in and out of the hospital slowed the process down. CMA/SSD X stated she was not aware of the resident's concerns regarding his preference for staff to give his medications after he eats. CMA/SSD X confirmed that residents should be interviewed on admission and routinely throughout their stay regarding their preferences and that residents have the right to participate in decisions and provide input regarding their care. She stated that when a resident reported concerns to the staff, the concerns should be relayed to the supervisor, forwarded to social services, and then addressed with the appropriate department in a timely manner. CMA/SSD X stated that the concerns and grievances are followed up on, and changes are made to the care if indicated based on the resident's preferences. She confirmed Resident R6's Care Plan had not been updated to direct staff regarding his preferences for mealtimes in relation to his medication administration. On 09/16/25 at 02:01 PM, Dietary Staff BB reported meals were served in the dining room at 08:00 AM for breakfast, 12:00 PM at lunch, and 05:00 PM at supper, but the residents who ate in their rooms received their trays approximately 30 to 45 minutes later.On 09/16/25 at 03:42 PM, CMA R confirmed she administered medications to Resident R6 and that he had voiced his preference to have his medications after he ate or when he asked for them. CMA R said Resident R6's medications were not ordered to be given with or after foodOn 09/17/25 at 02:30 PM, Administrative Nurse D confirmed that residents should have the opportunity to participate in decisions about their care, which included accommodation of their preferences regarding their medications. She stated residents' preferences and refusals of care and or services should be followed up by making the nurses aware and notifying the appropriate staff, and adjusting the resident's care as indicated to promote the resident's dignity and independence. She verified the resident's request for adjustment to meal service times and/or medication times had not been communicated as expected, and the facility had not followed up as they should.The facility did not provide a policy to address the reasonable accommodation of resident preferences.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clearwater Nursing & Rehabilitation Center

620 E Wood Street Clearwater, KS 67026

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

work until verification of the in-service training was obtained.2. Resident R1 was accepted to another facility with an estimated discharge date of 11/01/25 or sooner.3. To ensure Resident R1 received his Depo-Provera, the Director of Nursing added the administration date to her calendar as a reminder to ensure that the medication was on hand by the due date every two weeks.4. All staff were educated on 09/17/25 regarding Resident R1's specific behaviors that indicate that Resident R1 might be escalating and the appropriate actions to take in response.5. The facility had a recent change in Administrator and Director of Nursing staff, and the new staff were in-service

on 09/17/25 to do a root cause analysis when a resident was placed on one-to-one monitoring, which included what led up to the incident, what behaviors led up to the incident, and what to look for after the resident was removed from one-to-one monitoring. The entire interdisciplinary Team (IDT) also received this in-service on 09/17/25.6. The facility and corporate entity modified the current one-to-one policy to create ongoing monitoring once residents were removed from the one-to-one oversight, with regional support to monitor the effectiveness of interventions placed.7. The facility conducted a Quality Assurance and Performance Improvement (QAPI) meeting on 09/17/25 to review. On 09/17/25 at 05:05 PM, the surveyors verified implementation of the above corrective actions to address the immediacy as listed on the template.

The scope and severity remained at a G to represent the actual psychosocial harm, using the reasonable person concept, since Resident R2, Resident R3, and Resident R4 were cognitively impaired and unable to effectively communicate impact of the physical and sexual abuse experienced.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clearwater Nursing & Rehabilitation Center

620 E Wood Street Clearwater, KS 67026

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

The facility reported a census of 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on interview, and record review, the facility failed submit a completed investigation for allegations of resident-to-resident abuse to the State Agency within five working days as required for allegations involving Resident (R) 1 and Resident R2 on 06/21/25 and Resident R1 and Resident R3 on 06/28/25.Findings Included:- The facility provided an initial report to the SA for a resident-to-resident involving Resident R1 and Resident R2 in Incident KS00196132 and for Resident R1 and Resident R3 in Incident KS00196270.Resident R1's Progress Note on 06/21/25 at 03:08 AM documented staff witnessed Resident R1 in the dining room with a female resident [Resident R2]. The noted recorded staff witnessed both residents slapping each other on the arms, Resident R1 grabbed the female resident's arm, and staff immediately intervened and separated the residents.Resident R1's Progress Note on 06/28/25 at 11:03 AM, documented staff notified Resident R1's representative that staff observed Resident R1 touching a female resident in the genital area and Resident R1 would be monitored on a one-to-one basis. The note recorded Resident R1's representative stated they did not know how staff would stop Resident R1 from doing that.The facility could not provide an investigation related to the 06/21/25 and 06/28/25 incidents. The facility was unable to provide evidence the completed investigations were submitted to the SA within five working days.During an interview on 09/17/25 at 10:25 AM, Administrative Staff A stated he expected all reportable incidents to be thoroughly investigated and the completed investigation to be submitted in the time frame allowable. Administrative staff A was unable to provide the completed investigations and confirmed he was not working in the facility at the time of the previous events on 06/21/25 and 06/28/25 so he was not sure if anything was submitted to the SA or when. The facility's policy Abuse Prevention Program dated May 2025 documented the Administrator, or his/her designee, will 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clearwater Nursing & Rehabilitation Center

620 E Wood Street Clearwater, KS 67026

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

The facility reported a census of 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on interview, and record review, the facility failed to thoroughly investigate allegations of abuse for allegations involving Resident (R) 1 and Resident R2 on 06/21/25 and Resident R1 and Resident R3 on 06/28/25.Findings Included:- The facility provided an initial report to the SA for a resident-to-resident involving Resident R1 and Resident R2 in Incident KS00196132 and for Resident R1 and Resident R3 in Incident KS00196270.Resident R1's Progress Note on 06/21/25 at 03:08 AM documented staff witnessed Resident R1 in the dining room with a female resident [Resident R2]. The noted recorded staff witnessed both residents slapping each other on the arms, Resident R1 grabbed the female resident's arm, and staff immediately intervened and separated the residents.The facility could not provide an investigation related to the 06/21/25 incident.Resident R1's Progress Note on 06/28/25 at 11:03 AM, documented staff notified Resident R1's representative that staff observed Resident R1 touching a female resident in the genital area and Resident R1 would be monitored on a one-to-one basis. The note recorded Resident R1's representative stated they did not know how staff would stop Resident R1 from doing that.The facility could not provide an investigation related to the 06/28/25 incident.During an interview on 09/17/25 at 10:25 AM, Administrative Staff A stated he expected all reportable incidents to be thoroughly investigated and the completed investigation to be submitted in the time frame allowable. Administrative staff A was unable to provide the completed investigations and confirmed he was not working in the facility at the time of the previous events

on 06/21/25 and 06/28/25 so he was not sure if anything was completed. The facility's policy Abuse Prevention Program dated May 2025 documented if an actual incident, suspected incident or allegation of resident abuse, mistreatment, neglect or injury of unknown source or reasonable suspicion of a crime was reported, the Administrator would assign the investigation to an appropriate individual. and provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator would keep the resident, and his/her representative (sponsor) informed of the progress of the investigation and suspend immediately any employee who has been accused of resident abuse, pending

the outcome of the investigation. The Administrator would ensure that any further potential abuse, neglect exploitation or mistreatment as prevented. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet