Oaks of Clearwater, the

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the kitchen met sanitation requirements for one kitchen of one during 3 days (09/30/2025, 10/01/2025 and 10/02/2025) of three days observed.

Inspectors wroteBased on record review and interviews, the facility did not ensure a water management plan was in place to assess, identify and monitor for Legionella and other opportunistic waterborne pathogens.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure resident rooms, resident equipment and shower rooms equipment were maintained in a clean and sanitary manner during three days (9/30/2025, 10/1/2025, and 10/2/2025) of three days observed.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure an effective pest control program related to small flying insects in the kitchen, during two days (9/30/2025 and 10/1/2025) of three days observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was provided to notify when Medicare covered services would terminate and inform the beneficiary of the right to appeal the decision, for three residents (#31, #40, and #55) of three residents sampled for the provision of the NOMNC.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to obtain Level II Pre-admission screening and resident reviews (PASARR) for two residents (#8 and #9) of twenty-five initially sampled residents.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to obtain an accurate Preadmission Screening and Resident Review (PASARR) for one resident (#9) of twenty-five sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure ambulatory residents did not have access through an unlockable door to a functioning four-burner glass top stove located in one of two activity/dining rooms on the west hall for three residents (#23, #39, #45) of 27 sampled residents and failed to ensure safety of handrails for one handrail of one located next to the nursing station.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to address pharmacy recommendations for one resident (#9) of five residents sampled for the unnecessary administration of medications.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Thirty-one medication administration opportunities were observed, and four errors were identified for three residents (#50, #25 and #46 ) of eight residents observed. These errors constituted a 12.9% medication error rate. 1). On 9/30/25 at 11:15 a.m. an observation of medication administration with Staff K, Licensed Practical Nurse (LPN)/Charge Nurse (CN) was conducted with Resident #50. The staff member obtained a blood glucose level from the resident. The staff member returned to the medication cart, cleaned the glucometer and reviewed the resident's insulin sliding scale order for insulin lispro. Staff K removed the resident's Kwik pen of insulin lispro [NAME] (opened 9/25), applied a needle to the cartridge and dialed the dosage selector to 8 (units). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure documentation was accurate and complete in the Electronic Medical Record (EMR) for one resident (#35) out of 13 residents reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate a voiced grievance for one resident (#3) out of four sampled residents.

Inspectors wroteBased on resident record review, resident and staff interviews, observations, and policy and procedure review, the facility did not ensure an injury of unknown origin was thoroughly investigated in a timely manner for one resident (#1) of three residents reviewed for alleged violations of abuse and mistreatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain confidentiality of Protected Health Information (PHI) related to a bulletin board located in one of one nurses' station for a census of 52 residents related to having Do Not Resuscitate (DNR), mobility, tube feeding, and dialysis status being visible and accessible to visitors, residents, and staff members. The information was displayed at the nurse's station and the East Wing hallway bulletin board.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a safe, clean and homelike environment for six resident rooms (#200, #202, #207, #212, #213, and #224) of 22 rooms in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure food was labeled and dated when stored in the walk-in refrigerator, the walk-in refrigerator log was completed daily and the dishwasher was functioning properly in accordance with professional standards for food service safety in one of one kitchen with the potential to affect 51 of census of 52 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one resident (#209) of six residents observed for in-room dining and two residents (#4 and #26) of nine residents observed for communal dining received a dignified dining experience.

Inspectors wroteBased on record review and interview the facility failed to accurately assess a discharge on the Minimum Data Set (MDS) for one resident (#56) of three residents reviewed for transfer and discharge.

Inspectors wrote3. A review of Resident #18's admission Record revealed she was admitted to the facility on [DATE], with diagnoses to include major depressive disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the PASARR Level I Screen, dated 6/30/21, Section I - Decision Making A. and B, revealed it was not completed to reflect Resident #18's mental illness. During an interview on 09/19/23 at 3:00 p.m. Director of Nursing (DON) stated that Residents #18, #30 and #45's PASARRs should have been updated to show the new diagnosis of serious mental illness after admission and submitted for a Level II. The DON stated the facility had never really had a process for PASARRs before besides just reviewing them upon admission, but the facility will now develop a PASARR process. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to revise the person centered care plan to reflect the use of the word mama to communicate and identify the needs by one resident (#37) with communication limitations of thirty-two residents sampled.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accommodations were in place related to visual impairment for one resident (#47) out of thirty-two sampled residents.

Inspectors wroteBased on observation, record review and interview the facility failed to provide nail care related to trimming and cleaning fingernails for one resident (#7) of thirty-two residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one resident (#41) of two residents reviewed for respiratory services was administered oxygen at the physician ordered flow rate.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure proper infection control practices were implemented for two (#42 and #209) out of two residents on isolation precautions out of a total of thirty-two residents sampled.

Inspectors wroteBased on observation, interviews, and policy review facility did not ensure the call bell system was accessible to eleven residents (#28, #47, #13, #16, #15, #41, #54, #40, #26, #5, #4) out of thirty-two residents sampled and did not ensure a call system was accessible at one toilet out of twenty-two toilets in resident rooms.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to provide the resident or representative with detailed written notice of discharge and hospital transfers for two (#6, #35) of two residents reviewed for discharge.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to provide the resident or representative documentation of the facility's bed hold policy for two (#6, #35) of two residents reviewed for discharge.

Inspectors wroteBased on observation, interview and policy review, the facility failed to post Nursing Staffing information that included all the required elements on two of three days observed.

Inspectors wroteBased on observation, staff interview, and review of food and nutrition services documentation, the facility failed to hold cold Time/Temperature Control for Safety (TCS) food at 41 degrees Fahrenheit (F) or below during refrigerated storage during 2 observations, hot food at 135 degrees F or above during holding on the steam table for the breakfast meal, and maintain four kitchen utensils in good condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure behavioral monitoring related to psychotropic medications was performed for one resident (#13) of five residents reviewed for unnecessary medications.