Clearwater Nursing Center Cited for Serious Deficiencies
Libby Hastings • October 6, 2025
Clearwater Nursing Center Cited for Serious Deficiencies, Including Resident Sexual Abuse
KABC routinely reviews nursing home inspection reports to help families stay informed and advocate for safe, quality care. A recent inspection of Clearwater Nursing Center, Clearwater, completed in September 2025, uncovered serious deficiencies, including a substantiated case of resident-to-resident sexual abuse.
Key Findings from the Inspection
Inspectors documented multiple failures at Clearwater Nursing Center:
- Failure to protect residents from sexual abuse. The report describes an incident where a resident sexually assaulted another resident. Staff failed to ensure adequate supervision and safeguards, resulting in direct harm. Protecting residents from abuse is one of the most basic obligations of any nursing facility.
- Delayed and inadequate response to the abuse incident. Staff did not act quickly enough to separate residents, report the incident, or ensure proper protections were in place afterward.
- Medication administration errors. Inspectors found lapses in following physician orders and proper procedures for giving medications, creating unnecessary health risks.
- Inadequate infection control practices. Staff did not consistently follow hand hygiene and PPE protocols, exposing residents to preventable infections.
- Poor care planning and follow-up. Care plans were not updated to reflect residents’ changing needs, leaving them vulnerable to gaps in treatment and support.
The Facility’s Right to Appeal
Clearwater Nursing Center has the right to appeal these findings. Facilities may contest deficiencies if they believe inspection results are inaccurate. However, while the appeal process unfolds, these serious deficiencies remain on record and available to the public.
Why This Matters
No resident should ever experience abuse, neglect, or unsafe conditions in a nursing home. Federal regulations are in place to protect the health, dignity, and rights of older Kansans. When facilities fail to meet these standards, residents pay the price.
At KABC, we stand firmly with residents and families. We advocate for stronger protections, more effective oversight, and a long-term care system that prioritizes people over profits. Families deserve to know when problems occur, and residents deserve to live in environments where they are safe from harm.
For those who want to learn more, inspection reports
are available through the Kansas Department for Aging and Disability Services. A copy of the report mentioned above can be found here. KABC is also here to help families understand deficiencies and take action to advocate for their loved ones.
On March 19, 2026, a Washington Post article highlighted a recent Office of Inspector General for the Department of Health and Human Services investigation that brought renewed national attention to a troubling reality inside America’s nursing homes: powerful antipsychotic drugs are being used not as treatment, but as control. The report found that some facilities are misdiagnosing residents with schizophrenia to justify prescribing antipsychotic medications. These drugs are often not approved for people with dementia and carry serious risks, including falls, strokes, and even death. In many cases, these medications are used to manage behaviors that are not dangerous, such as calling out, resisting care, or expressing distress. The result is what advocates have long warned about: the use of chemical restraints to sedate residents for staff convenience. A National Problem Decades in the Making The misuse of antipsychotic drugs in long-term care has been documented for years. In April 2024, KABC highlighted this issue in our advocacy work, noting that hundreds of thousands of nursing home residents nationwide are given antipsychotic medications, often without appropriate clinical justification. These drugs carry an FDA “black box” warning for use in older adults with dementia due to an increased risk of death. Federal efforts over the past decade have aimed to reduce unnecessary use, yet as of early 2026, approximately 17% of long-stay nursing home residents in the United States are still receiving antipsychotic medications. At the same time, recent federal policy discussions in March 2026 have raised concerns among advocates that loosening reporting requirements could reverse progress made in reducing inappropriate use. Kansas Is Not Immune This issue hits close to home. In 2022, the Kansas Legislature’s Senior Care Task Force released a report to the 2023 Legislature identifying the administration of antipsychotic medications and protections against abuse and neglect as critical areas for reform. The Task Force emphasized that these medications could have serious and even fatal consequences for older adults, particularly when used inappropriately. Advocates in Kansas have reported that up to 26% of nursing home residents, and nearly 40% of those with dementia, have been prescribed antipsychotic medications in recent years, despite well-documented risks. While some facilities have made progress, reductions in use have stalled in recent years, raising concerns that systemic issues remain unresolved. Why It Happens At its core, the misuse of antipsychotic drugs is often a symptom of deeper systemic problems, many of which have been exacerbated since the COVID-19 pandemic. Experts and investigators point to: Chronic understaffing, intensified since 2020 Lack of training in dementia care Pressure to manage behaviors quickly Lack of person-centered practices in care Gaps in oversight and accountability Non-drug approaches, like personalized care, meaningful activities, and addressing unmet needs, are widely recognized as best practice. But they require time, staffing, and resources that many facilities continue to lack in 2026. When those supports are missing, medication restraint becomes the default. What Proper Care Should Look Like Clinical guidance has long been clear, and yet remains unchanged in 2026. Antipsychotic medications should be a last resort, used only when: Non-drug interventions have failed The resident poses a risk to themselves or others The benefits outweigh the serious risks Even then, they should be used cautiously, closely monitored, and regularly reevaluated. The Path Forward for Kansas Kansas has an opportunity, and an obligation, to act. Building on the 2022 Senior Care Task Force recommendations, advocates continue in 2025–2026 to call for: Expanded access to geriatric mental health specialists Stronger oversight and enforcement Improved training in dementia and person-centered care Greater transparency for residents and families Meaningful solutions to the ongoing staffing crisis At its heart, this is about dignity. Older adults in Kansas adult care homes deserve care that respects their humanity, not treatment that silences it.
Kansas Advocates for Better Care testified on FE waiver funding and supported bills on decision-making, dementia training, and memory care standards.