Clearwater Nursing & Rehabilitation Center

Findings included: - The Electronic Medical Record (EMR) for R22 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin,) cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain,) chronic respiratory failure (a long-term condition where the respiratory system struggles to adequately exchange oxygen and carbon dioxide, leading to dangerous low oxygen or high carbon dioxide levels in the blood,) hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood,) and syncope (fainting or passing out). R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R22 was dependent upon staff assistance for toileting hygiene, personal hygiene, and to shower/bathe herself. R22's Care Plan, dated 06/03/25, directed staff to monitor and report any signs or symptoms of coronary artery disease, chest pain or pressure, especially with activity, heartburn, nausea and vomiting, shortness of breath, and excessive sweating due to R22's altered cardiovascular status. R22's Progress Notes dated 02/07/26 at 12:44 PM, documented R22 complained of chest pain and shortness of air. R22 was alert and oriented.

Staff obtained vital signs, and her blood pressure was 147/98 millimeters (mm) of mercury (Hg) and her pulse was 111 beats per minute.

Emergency Medical Services transported R22 to the hospital for further evaluation and treatment. R22's Progress Notes dated 02/07/26 at 04:46 PM, documented R22 was admitted to the hospital for observation. R22's clinical record lacked evidence that a copy of the bed hold policy was provided to the resident or representative when she was transferred to the hospital. On 06/01/26 at 11:10 AM, observation revealed R22 lying in bed. On 06/02/26 at 10:00 AM, Administrative Nurse D verified R22 did not have a bed hold in her records and stated they should have had a bed hold notice provided to R22 and her responsible party.

The facility's Bed Hold policy undated, documented before the facility transfers a resident to the hospital the resident goes or therapeutic leave, the facility would provide written information to the resident and/or resident representative that specifies the duration of the state bed-hold policy during which the resident is permitted to return and resume residency in the facility.

The reserve bed payment policy in the state plan; the facility's policies regarding bed-hold period, which are consistent with the law permitting the resident to return.

All information provided to a resident and/or representative requires a signature of receipt of the policy by the resident and/or representative, including bed hold information provided at the time of admission and bed hold information provided at the time of discharge/transfer related to hospitalization and/or therapeutic leave.

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Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

actions that can be measured.

observation, record review, and interview, the facility failed to develop a comprehensive care plan

R34's Electronic Medical Record (EMR) documented he had a diagnosis of mastoiditis (serious bacterial infection of the skull just behind and below the ear). R34's admission Minimum Data Set (MDS), dated [DATE], documented R34 as a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition.

The MDS documented R34 required supervision with most activities of daily living (ADLs).

The MDS documented that the resident had surgical wounds and received surgical wound care.

The Care Area Assessment, CAA, dated 05/04/26, documented Resident triggered for potential skin breakdown d/t supervision needed to maintain ADL function.

Surgical wound care and had a diagnosis of osteomyelitis (local or generalized infection of the bone and bone marrow)R34's Care Plan, revised 05/20/26, acknowledged information regarding the resident's surgical wounds.

The plan lacked instructions to staff on how to care for R34's surgical wounds.On 06/03/26 at 02:00 PM, observation revealed R34 sat in a wheelchair in the therapy room with a dressing on the top of his head and behind his left ear.The Nurse's Note, dated 04/29/26, documented R34 admitted to the facility from the hospital. He had removal of squamous cell carcinoma (slow-growing type of cancer) a few months ago with flap and skin graft failure. R34 was then brought back to the hospital for debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) of the scalp wound and closure with split-thickness skin graft (part of skin implanted to cover areas where skin was lost through burns or injury) and muscular cutaneous flap (surgical reconstructive technique that transfers a block of tissue consisting of an underlying muscle, its overlying skin, and the fat between them. He had also developed osteomyelitis and mastoiditis. On 06/02/26 at 09:25 AM, Licensed Nurse (LN) G verified that the skin integrity section of the care plan lacked interventions or instructions for staff on how to care for his wounds. LN G stated she goes by R34's care instructions on the Treatment Administration Record (TAR). LN G stated that if an agency nurse worked at the facility, she could see how the nurse would not know how to care for R34's wounds by looking at his care plan.On 06/02/26 at 01:00 PM, Administrative Nurse E verified R34's verified R34's skin integrity section in his care plan lacked instructions to staff on how to care for his surgical wounds, and they should be on it.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Findings included:- R39's Electronic Medical

the body becomes congested with fluid), and urinary retention (lack of ability to urinate and empty the bladder).

The Quarterly MDS, dated 03/19/2026, documented R39 had intact cognition. R39 was independent in toileting, personal hygiene, and mobility.

The MDS further documented R39 had lower functional impairment on both sides, required supervision with transfers, and received diuretic medication daily. R39's 04/14/2026 Care Plan included the following interventions for R39: 10/23/2025- Inspect R39's skin daily with cares, administer medications as ordered, monitor and report any pertinent laboratory results to the physician, monitor vital signs as ordered, and notify the physician of any abnormalities.

Monitor, document, and report as needed any signs of dependent edema in the legs and feet.

The care plan lacked direction to the staff regarding wrapping his legs with Ace wraps (a stretchable cloth wrap designed to provide localized pressure, reduce swelling, and support weak or injured muscles and joints) or that R39 refused the wraps.

The Physician Order, dated 12/08/2025, directed staff to apply Ace wraps up to mid-thigh (the section of the lower limb that extends between the hip and the knee) in the morning and remove at bedtime.

The Treatment Administration Record, dated June 2026, documented that staff applied the Ace wraps on the following days:06/01/202606/02/2026 On 06/01/2026 at 10:21 AM, R39 had on gripper socks and did not have on the Ace wraps as ordered. R39 stated that he was to have his legs wrapped every day, but that it rarely happened unless he reminded them to do it. On 06/01/2026 at 03:00 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered. On 06/02/2026 at 01:50 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered. On 06/02/2026 at 02:13 PM, Licensed Nurse (LN) G stated that staff tried to get R39 to wear the wraps every day, but he would refuse. LN G stated that she had charted that she had applied the Ace write the last two days and verified that R39 had not had them on. LN G asked if she should go in and change the charting, then said she would go to R39 and offer to put on the Ace wraps. On 06/03/2026 at 09:00 AM, Administrative Nurse D stated that if R39 did not want the Ace wraps, staff are to document that he refused and should not document that they were applied when they were not.

The facility's Quality of Care policy, dated 10/2021, documented that the facility was committed to providing high-quality care and services to residents in a safe, respectful, and person-centered environment.

The facility staff members would be highly trained, qualified, and dedicated to providing compassionate care.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Findings included:- R39's Electronic Medical Record (EMR) documented diagnoses of edema, heart failure (a condition with low heart output and the body becomes congested with fluid), and urinary retention (lack of ability to urinate and empty the bladder).R39's admission Minimum Data Set (MDS), dated [DATE], documented R39 had intact cognition. R39 was independent with toileting hygiene, personal hygiene, transfers, and mobility.

The MDS further documented R39 had lower functional impairment on both sides and received diuretic (a medication to promote the formation and excretion of urine) medication daily.The Quarterly MDS, dated 03/19/2026, documented R39 had intact cognition. R39 was independent in toileting, personal hygiene, and mobility.

The MDS further documented R39 had lower functional impairment on both sides, required supervision with transfers, and received diuretic medication daily.R39's 04/14/2026 Care Plan included the following interventions for R39:10/23/2025- Inspect R39's skin daily with cares, administer medications as ordered, monitor and report any pertinent laboratory results to the physician, monitor vital signs as ordered, and notify the physician of any abnormalities.

Monitor, document, and report as needed any signs of dependent edema in the legs and feet.

The care plan lacked direction to the staff regarding wrapping his legs with Ace wraps (a stretchable cloth wrap designed to provide localized pressure, reduce swelling, and support weak or injured muscles and joints) or that R39 refused the wraps.The Physician Order, dated 09/27/2025, directed staff to administer spironolactone (a diuretic medication), 50 milligrams (m), by mouth, daily for edema.The Physician Order, dated 12/08/2025, directed staff to apply Ace wraps up to mid-thigh (the section of the lower limb that extends between the hip and the knee) in the morning and remove at bedtime.The Treatment Administration Record, dated May 2025, documented that staff applied the Ace wraps on the following days:05/01/202605/06/202605/11/202605/20/202605/21/202605/25/2026The Nurse's Notes for the above dates documented that R39 did not have the wraps when they went to remove them or that R39 had refused them.The Treatment Administration Record, dated June 2026, documented that staff applied the Ace wraps on the following days:06/01/202606/02/2026On 06/01/26 at 10:21 AM, R39 had on gripper socks and did not have on the Ace wraps as ordered. R39 stated that he was to have his legs wrapped every day, but that it rarely happened unless he reminded them to do it.On 06/01/26 at 03:00 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered.On 06/02/26 at 01:50 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered.On 06/02/2026 at 02:13 PM, Licensed Nurse (LN) G stated that staff tried to get R39 to wear the wraps every day, but he would refuse. LN G stated that she had charted that she had applied the Ace write the last two days and verified that R39 had not had them on. LN G asked if she should go in and change the charting, then said she would go to R39 and offer to put on the Ace wraps.On 06/03/2026 at 09:00 AM, Administrative Nurse D stated that if R39 did not want the Ace wraps, staff are to document that he refused and should not document that they were applied when they weren't.The facility's Quality of Care policy, dated 10/2021, documented that the facility was committed to providing high-quality care and services to residents in a safe, respectful, and person-centered environment.

The facility ensured all residents received the highest standard of care, promoting each resident's physical, emotional, social, and psychosocial well-being and aiding in fostering a culture of continuous improvement and helping guide staff to deliver exceptional care to all residents.

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Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

inside and went to lunch. In an interview on 06/01/26 at 03:45 PM, Dietary Staff CC said he was in his

jeopardy to resident health or truck, so his coworker gave him the keys to her car, and he went looking for him.

Staff told him they safety saw on the camera R14 heading north.

They went down one street with posted speeds of 35 mph, went over the railroad tracks, and saw R14 walking toward the local C0-op. He pulled down a little dirt

CC called other staff to where the resident was, and they loaded R14 into the car.

Dietary Staff CC stated it was very hot outside, so when he got back, staff gave him fluids and food. On 06/01/26 at 01:45 PM, Administrative Nurse D stated the facility video camera footage revealed R14 was last seen on 05/15/26 at 11:34 AM outside in the parking lot /designated smoking area and was visualized on camera.

She stated the camera revealed R14 exited from the unalarmed, unsecured smoking area.

She said staff delivered a room tray to the resident's room at some point, but no one noticed the resident was missing until dietary staff went to pick up his room tray at 01:43 PM.

Administrative Nurse D verified the resident was found at 02:04 PM and was transported back to the facility, with no injuries noted.

Administrative Nurse D verified the resident had an elopement risk with cognitive impairment and should not have been unattended when he was outside.

Administrative Nurse D verified the facility changed the location of the smoking area to the outdoor patio/gazabo area that was secured with a fence and exit doors that alarmed, and the resident continued to be monitored during smoke breaks.

The facility's Wandering and Elopement policy, dated March 2025, documented the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. If an employee observes a resident leave the premises, he/she should. a.

Attempt to prevent the residents from leaving in a courteous manner. b. get help from other staff members in the immediate vicinity, if necessary; and c. instructs another staff member to inform the charge nurse or director of nursing that a resident is attempting to leave. If a resident is missing, initiate the elopement/missing resident emergency procedure. a.

Determine if the resident is out on an authorized leave or pass, b. If the resident was not authorized to leave, initiate a search of the building and premises; and c. If the resident is not located, notify the administrator, the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and as necessary, volunteer agencies like emergency management, rescue squads, etc.) When the resident returns to the facility, the director of nursing or charge nurse shall: a.

Examine the resident for injuries. b.

Contact the attending physician and report findings and conditions of the resident. c.

Notify the resident's legal representative (sponsor). d.

Notify the search teams that the resident has been located:e.

Complete and file incident report; and f.

Document relevant information in the resident's medical record. On 06/02/26 at 03:23 PM, Administrative Staff A and Administrative Nurse D received the Immediate Jeopardy [IJ] Template and were notified of the facility's failure to provide adequate supervision to prevent an elopement for R14 placed the resident in immediate jeopardy.

The facility identified and implemented immediate corrective actions completed by 05/16/26, which included all staff in-service on meal protocols, smoking supervision and safety, and supervision of all residents.

All residents had a new elopement assessment completed on 05/15/26.

An elopement drill was conducted on 05/15/26 for the 06:00 PM- 06:00 AM, and 05/17/26 for the 06:00 AM-06:00 PM shift.

The smoking area was moved to a secure courtyard on 05/15/26.

All residents who smoked had an updated smoking assessment.

All residents with Wander Guards were checked for functionality.

Staff completed a trauma assessment for R14.

Dietary began using the reconciliation form for each meal.

Due to all corrective actions being completed before the onsite survey, the citation was deemed past noncompliance and existed at a J (isolated, immediate jeopardy) scope and severity.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Findings included:- R16's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and pleural effusion (abnormal accumulation of fluid in the lungs).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition. R16 was dependent upon staff for all activities of daily living. R16 had shortness of breath (SOB) with exertion, at rest, and when lying flat. R16 required the use of oxygen therapy and used a non-invasive mechanical ventilator daily.R16's 05/13/2026 Care Plan included the following interventions for R16:11/03/2025- Assist R16, family, and caregivers in learning signs of respiratory compromise, encourage sustained deep breaths, and ask her to yawn, maintain a clear airway by encouraging her to clear her own secretions with effective coughing.

Monitor and document changes in orientation, increased restlessness, anxiety, and air hunger.

Monitor her breath patterns and report any abnormalities to the physician, position her with proper body alignment for optimal breathing patterns, and administer medication as ordered. R16's care plan directed staff to ensure her Bipap settings as ordered and was on continuous oxygen at 3 liters (L) per nasal cannula (a lightweight, flexible medical device used to deliver supplemental oxygen directly into the nostrils).The Physician's Order, dated 03/16/26, directed staff to administer 1 ipratropium-albuterol solution (a sterile inhalation solution), 0.5-2.5 (3) milligram (mg)/3 milliliter (ml) nebulizer treatment every four hours for SOB.On 06/01/2026 at 10:16 AM, R16's nebulizer mouthpiece was lying on the bed next to her. R16's BIPAP tubing was disconnected from the oxygen concentrator and was lying on the floor unbagged.On 06/02/2026 at 09:15 AM, R16's nebulizer mouthpiece was lying on the bed next to her. R16's BIPAP tubing was disconnected from the oxygen concentrator and was lying on the floor unbagged.On 06/03/2026 at 07:00 AM, R16's nebulizer mouthpiece was lying on the bed next to her. R16's BIPAP tubing was disconnected from the oxygen concentrator and was lying on the floor unbagged.On 06/02/2026 at 09:00 AM, Certified Medication Aide (CMA) R verified the tubing should be in the bags provided.On 06/03/2026 at 07:30 AM, Administrative Nurse D stated the tubing from the BiPAP should be placed in the bag that was on the oxygen concentrator.

Administrative Nurse D further stated R16 liked to have the nebulizer mouthpiece lying next to her on the bed and stated she would make sure that R16's preferences were on the care plan.The facility's Administration of Oxygen undated policy, documented staff are to store all nebulizer masks and tubing in labeled and dated plastic bags.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Findings included:- On 06/02/2026 at 10:13 AM, R19 ambulated in the hall with a walker. LN G asked R19 if she was ready to receive her insulin, and R19 replied yes and entered her room. LN G followed her in with a plastic container that held a Humalog, 100 UNIT/milliliter (ml) [NAME] Pen, LN G clicked up seven units of insulin in the pen, then, without priming the pen (a procedure which removes the air from the needle and cartridge that may collect during normal use, ensuring that the pen is working correctly), administered the insulin in R19's left arm. LN G verified she had not primed the insulin and stated she was unaware she was supposed to.

Upon request, the facility was unable to provide LN G's nursing skills check sheet.Review of a blank nursing skills check: medication pass check sheet revealed a lack of competency assessment regarding priming an insulin Kwik Pen.

The Insulin Kwik Pen Instructions Pamphlet instructed staff to prime an insulin Kwik Pen before each injection.

Priming your pen means. the pamphlet documented to prime a pen, turn the dose knob to select 2 units, hold your pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, continue holding your pen with the needle pointing up, push the dose know in until it stops, and 0 is seen in the dose window.

Hold the dose in and count to 5 slowly.

You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps no more than 4 times. If you still do not see insulin, change the needle and repeat priming steps 6 to 8 times. On 06/03/2026 at 08:51 AM, Administrative Nurse D stated she expected staff to prime the insulin pen with two units of insulin before administering it to a resident.

Administrative Nurse D stated that upon hire, nurses had to perform a competency check-off on insulin. On 06/03/26 at 09:50 AM, Administrative Nurse D verified that the nursing skills check lacked a competency check regarding priming an insulin kwikpen.

Administrative Nurse D stated she could not find LN G's nursing skills check sheet.

The facility's Competency of Nursing Staff Policy, undated, documented that the facility and resident -specific competency evaluations would be conducted upon hire, annually, and deemed necessary based on the facility assessment.

All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Findings included:-

Review of the

lacked a Registered Nurse on the following dates:03/16/26,03/21/26 and 03/22/26.04/04/26 and 04/18/26.05/02/26, 05/03/26, 05/16/26, 05/23/26, 05/24/26 and 05/31/26. On 06/03/26 at 09:00 AM, Administrative Nurse D verified the facility did not have a Registered Nurse in the building for eight consecutive hours or working as a charge nurse for the above documented dates.

The facility's Registered Nurse policy, dated January 2024, documented the facility would employ the services of an RN for at least eight consecutive hours a day, seven days a week.

The facility would designate an RN to serve as the Director of Nursing (DON) on a full-time basis.

The policy documented the DON may serve as a charge nurse only when the facility has an average daily census of 60 or fewer residents.

The RN hours would be recorded and reported on staffing sheet and would be reported on the Payroll Based Journal (PBJ) reporting system.

Per Facility Assessment, the facility may identify when the residents of the facility require the services of an RN for more than eight hours a day based on the acuity level of the resident population, The facility may choose a variety of hours of duty such as an eight hour or a twelve hour shift, but the facility would always ensure eight consecutive hours of RN service every day, seven days per week.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

number of in-service training hours per year.

This placed the residents at risk of impaired care.

at the facility for at least one year.

The facility's in-service records documented that 5 of those nurses' aides reviewed had not completed the required 12 hours of in-service training in the past year.Certified Nurse Aide (CNA) N, hired 01/29/2024, lacked the required number of in-service hours and in-services based on performance evaluations. CNA O, hired 05/29/2025, lacked the required number of in-service hours and in-services based on performance evaluations.CNA P, hired 05/22/2025, lacked the required number of in-service hours and in-services based on performance evaluations.CNA Q, hired 02/24/2025, lacked the required number of in-service hours and in-services based on performance evaluations.Social Service Director (SSD) and CNA X, hired 10/13/2023, lacked the required number of in-service hours and in-service based on performance evaluations. On 06/03/25 at 09:30 AM, Administrative Nurse D stated she had been employed at the facility for approximately six weeks and was unable to find the documentation and failed to provide the hours needed by the nurse aide staff.

The In-Service Training Program, Nurse Aide,, dated May 2021, documented all nurse aides would participate in regularly scheduled in-service training classes.

The facility completes a performance review of nurse aides at least every 12 months. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses.

Annual in-services:Ensure the continuing competencies of nurse aides.Are no less than 2 hours per employment year.

Address areas of weakness as determined by the facility assessment.Addresses the special needs of the residents, as determined by the facility assessment.Include training that addresses the care of residents with cognitive impairment: and Include training in dementia management and abuse prevention.

All in-service classes attended by the employee are entered on the prospective employee's Record of In-Service by the department supervisor or other persons as designated by the supervisor

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Findings included:- On [DATE] at 08:30 AM, observation of the facility's treatment cart revealed the following:R6's Humalog (fast-acting insulin) FlexPen was not labeled with an open date or an expired date.R43's Lantus (long-acting insulin) flex pen was labeled with an opened date of [DATE] and an expired date of [DATE]. On [DATE] at 08:15 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and discard the expired insulin flex pens.

Medlineplus.gov directs open, unrefrigerated Humalog and Lantus can be used within 28 days; after that time, they must be discarded.

The facility's Administering Medications policy, dated [DATE], documented medications are administered in a safe and timely manner, and as prescribed.

The expiration/beyond use date on the medication label is checked prior to administering.

When opening a multi dose container, the date is recorded on the container.

Insulin pens containing multi dose of insulin are for single-resident use only.

Insulin pens are clearly labeled with the resident's name or other identifying information.

Prior to administering insulin with an insulin pen, the nurse verifies the correct pen is used for that resident.

The expiration beyond use date on the medication label is checked prior to administering.

When opening a multi-use container, the date is recorded on the container.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

the food and nutrition service, including a qualified dietician.

dietary manager for the 32 residents who resided in the facility and received meals from the facility

oven-roasted potatoes, carrots, and Jello parfait.On 06/02/2026 at 11:00 AM, observation revealed Dietary CC in the kitchen overseeing the preparation of the noon meal.On 06/01/2026 at 08:00 AM, Dietary CC stated he was not a Certified Dietary Manager (CDM) and had not been enrolled in any dietary certification classes.On 06/03/26 at 09:00 AM, Administrative Nurse D verified he was not certified and planned to enroll him in classes at the end of June.The facility's Food and Nutrition Services policy, dated 10/2021, documented the Food Services manager would be CDM certified or enrolled in an accredited CDM program and on pace for completion.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Based on interview, and record review, the facility failed to consistently provide a nourishing evening

the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).

Findings included:- On 06/02/2026 at 11:00 AM, during the resident council meeting, Resident (R) 18 and R22, stated they were diabetic and did not always have snacks available at night.

They stated that they used to have them at the nurse's station, but some residents were taking too many, and others would not receive one.

Both residents stated there were no sandwiches available if they wanted one, just apples, bananas, fig bars, and cheese crackers.On 06/02/2026 at 1130 AM, Dietary CC stated that he was working on a better selection of snacks for the residents during the evening.

Dietary CC stated that right now, he had Jell-O, pudding, and Cheetos that residents could have. He wanted to get a cabinet that they could lock up snacks that only staff could hand out.

Dietary CC further stated that he planned to provide different sandwiches for the residents and verified that he had not consistently provided protein snacks for the residents with DM. He stated that residents can ask for sandwiches when dietary staff are in the building, and before dietary staff leave the building, the staff are given the evening snacks for the residents.On 06/02/2026 at 02:15 PM, Licensed Nurse (LN) G stated that dietary staff bring the evening snacks, which are kept in a container underneath the nurses' station and are given to residents if they ask.On 06/03/2026 at 09:00 AM, Administrative Nurse D stated there were residents who would take a bunch of the snacks, and it did not leave enough for other residents.

Some residents had asked for grilled cheese sandwiches late at night, and the dietary staff was already gone for the night.

Dietary CC was working on a plan to make sure there were enough sandwiches and snacks for all the residents, and they planned to put a lock on a cabinet and a lock on the refrigerator for the cold items, like different sandwiches.The facility's Food and Nutrition Services policy, dated 10/2021, documented nourishing snacks are available to the residents 24 hours a day.

The residents may request snacks as desired, or snacks may be scheduled between meals to accommodate the residents' typical eating patterns.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

record temperatures.

Food Service Supervisors or designated employees would check the refrigerator

and more often as necessary.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

the QAPI plan.

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026

Findings included:1. On 06/01/26 at 10:00 AM, observation revealed R42 rested in bed on his back.

Certified Nurse Aide (CNA) N and CNA O donned a gown and applied gloves and entered R42's room. R42 reported to the CNAs that he needed incontinence care due to having a bowel movement.

CNA O gathered supplies, while CNA N pulled down the resident's pants and instructed him to turn onto his left side.

Further observation revealed CNA N pulled down the brief in the back to reveal a moderate amount of stool covering the backside and his wound dressing area. CNA N removed the brief and dressing and provided peri-care to R42's buttock area, then instructed R42 to turn on his back.

Further observation revealed CNA O provided peri-care to the residents' front peri area (private area) with the same soiled gloves, and then wearing the same gloves, placed a new incontinent brief underneath the resident and fastened it.

The CNAs then removed and discarded the gloves.

Observation revealed that both CNAs applied new gloves and assisted R42 in pulling up his pants, then doffed their gowns with gloves, placed them in a plastic bag, CNA O tied the bag, and both CNAs left the resident's room without washing their hands or using hand sanitizer. On 06/01/26 at 10:20 AM, CNA N verified that she had not changed gloves or washed her hands after providing incontinent care for R42 and stated that she usually washes her hands when entering another resident's room to provide care. 2. On 06/02/26 at 10:14 AM, observation revealed R12's breathing machine mask and tubing lying on the floor by a recliner, on top of a blue cloth bag, uncovered.

Licensed Nurse (LN) G verified the finding and asked R12 where the plastic bag was for the mask and tubing, and the resident did not answer. LN G laid the uncovered mask on top of an end table, stated she would get a bag and take care of the mask and tubing, and left the room. On 06/03/26 at 08:51 AM, Administrative Nurse D stated she expected staff to store a resident's breathing treatment, a mask, and tubing in a bag.

Administrative Nurse D stated she would expect staff to change gloves when providing incontinent care after dirty, and before they place a new incontinent brief on, and staff should wash their hands before and after providing care.

The facility's Administration of Oxygen Policy, undated, instructed staff to store equipment in a dated plastic bag and leave it at the bedside.The facility's Handwashing/Hand Hygiene Policy, undated, instructed staff to use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:Before and after coming on duty.B.

Before and after direct contact with residents.Before preparing or handling medications.Before performing a non-surgical invasive procedure.Before performing a non-surgical invasive procedure.Before donning sterile gloves.Before handling clean or soiled dressings, gauze pads, etc.Before moving from a contaminated body site to a clean body site during resident care.After contact with a resident's intact skin.After contact with blood or bodily fluids.After handling used dressings, contaminated equipment, etc.After contact with objects (medical equipment) in the immediate vicinity of the resident.After removing gloves.Before and after entering isolation precautions settings

175454 06/03/2026

Clearwater Nursing & Rehabilitation Center 620 E Wood Street Clearwater, KS 67026