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 October 1st and 2nd, the 2025 Special Committee on Health and Social Services met, with the first day devoted to nursing home surveying and credentialing. The joint committee of both House and Senate members heard from the Kansas Department for Aging and Disability Services (KDADS), the Long-Term Care Ombudsman, industry representatives from Kansas and out of state, administrators, and contractors. Notably absent were the voices of consumers, their family members, and facility staff , the people most affected by long-term care policy. The committee heard information about: Survey Backlogs and Staffing Challenges KDADS contracts with the federal government to inspect adult care homes for health and safety compliance. KDADS has struggled for years to meet federal requirements, due in large part to recruiting and retaining nurse surveyor positions. More than half of the 60 approved positions were vacant earlier this year. As a result, Kansas currently averages 19.9 months between nursing home inspections , far beyond the federal requirement of 12-15.9 months. With just over 300 federally licensed facilities in the state, timely inspections are critical to protecting residents. To address this, KDADS eliminated 15 vacant positions and raised starting pay: up to $60,000 for multidisciplinary surveyors and $67,000 for RNs . The agency is also considering incentives to encourage more RNs to work as surveyors. Kansas has one of the highest rates of the most serious deficiencies, known as Immediate Jeopardy (IJ) deficiencies, in the nation , citations for situations where resident health and safety are at serious risk. The committee explored the possibility of privatizing the survey process. Resident Rights at Risk Testimony also revealed troubling practices in some nursing homes, including charging residents $200–$300 per month in “pharmacy provider” or “medication set-up” fees if they choose to use an outside pharmacy. This practice undermines residents’ right to choose their own providers and unfairly penalizes private-pay residents, already shouldering an average of $7,000–$8,000 per month in nursing home costs. Involuntary Discharges and the Ombudsman’s Recommendation The Long-Term Care Ombudsman urged lawmakers to expand discharge reporting requirements. As she noted: “Federal regulations require a notice to be sent to our office for a facility-initiated transfer (involuntary discharge) in federally licensed nursing homes, but that is not the case for state licensed homes, assisted livings, home pluses and residential health care facilities. With the help of our office, we can often help resolve the reason for the discharge notice to prevent a resident transfer or support the resident to ensure a transition occurs safely.” The committee heard concerns from representatives of the nursing home industry and decided to delay making a recommendation on this issue, noting that additional information is needed. KABC has advocated for not only strengthening the reporting requirements but also giving residents of assisted living facilities the same right to appeal an involuntary discharge that nursing home residents enjoy. Raising the Personal Needs Allowance The Personal Needs Allowance (PNA) for nursing home residents is a monthly stipend that Medicaid recipients can use for personal expenses. In Kansas, the PNA is just $62 per month. Many residents express concern that this amount is insufficient to cover basic personal expenses such as haircuts or undergarments. An immediate increase to the allowance is needed, along with an ongoing adjustment to keep pace with rising costs. The Long-Term Care Ombudsman recommended a PNA increase to the national average of $72 with an additional annual Cost of Living Adjustment. KABC’s Position KABC will continue to advocate for: • Strong oversight of nursing homes. • Resident rights protections, including freedom of choice in providers. • Central inclusion of residents and staff voices in all policy discussions. You can watch the hearing on the Kansas Legislature’s YouTube channel here . KABC will continue to monitor these conversations closely as the 2026 legislative session approaches.
Kansas Advocates for Better Care hosted our annual Caregiver Training and Membership Meeting on September 18, 2025, featuring guest presenter Katie Tipton, COTA/L, Director of Business Operations at askSAMIE . Katie shared practical fall prevention strategies to help caregivers support older adults in maintaining independence and safety at home. Falls are the leading cause of injury and death for older Americans. More than one in four adults age 65+ experiences a fall each year, leading to over 3 million emergency department visits, 800,000 hospitalizations, and 32,000 deaths annually. Beyond the statistics, falls can also create a lasting fear of falling, which further limits independence and quality of life. Katie’s presentation highlighted: Understanding fall risks – from muscle weakness and balance issues to medication management and environmental hazards. Simple home modifications – such as removing loose rugs, improving lighting, and adding grab bars in the bathroom, where most falls occur. Caregiver roles – observing changes in mobility, encouraging safe habits like supportive footwear, and assisting with strength and balance exercises. Resources and adaptive equipment – including shower chairs, walkers, rollators, and occupational therapy home assessments. By taking these steps, caregivers can play a vital role in reducing fall risks, helping older adults stay safe, independent, and engaged in daily life. For those who were unable to attend, a recording of the training is available here , and Katie’s slides are available. If you have additional questions regarding this year's training topic, please contact Katie at katie@asksamie.com. During the business meeting, Molly Wood (President), Barbara Braa (Treasurer) & Deborah Merrill were unanimously voted in to retain their current board positions. There were no recommendations from the floor. Executive Director Dan Goodman discussed KABC’s legislative accomplishments for 2025.