Inspection visit

InspectionSeptember 10, 2021

OAKS OF CLEARWATER, THECMS #1053237 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: 1. Review of the Electronic Medical Record (EMR) 'Face Sheet' revealed Resident #6 was originally admitted to the facility on [DATE]. Further review of the EMR Census Tab revealed Resident #6 was transferred to the hospital on [DATE]. Additional review of the EMR revealed a nurse progress note dated 08/29/21 at 07:39 a.m. documenting a telephone message left for Resident #6's spouse requesting a call back related to the transfer of Resident #6 to the hospital. Further review of the paper record revealed an Agency for Health Care Administration (AHCA) form 3120-0002 Revised May '01 partially completed on 8/29/21 with under Notice received by: [name of resident#6's spouse] at the signature space verbal consent given and the signature of the nurse. No additional evidence was present in the clinical record related to the provision of a written notice of transfer. 2. Review of the EMR 'Face Sheet' revealed Resident #35 was originally admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Additional review of the EMR revealed a skilled nursing facility to hospital transfer form dated 07/31/21 at 3:08 p.m., the form documented the reason for the transfer of Resident #35 to the hospital. The form also documented a telephone notification of Resident #35's emergency contact. No additional evidence was present in the clinical record related to the provision of a written notice of transfer. On 09/09/2021 at 4:31 p.m. an interview with the Social Services Director (SSD) revealed she did not provide any written notifications other than to the ombudsman when a Resident transferred to the hospital. A subsequent interview was conducted on 09/09/2021 at 4:40 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated they were not sending paperwork in the mail, she stated nursing was sending some information with the resident to the hospital. The NHA confirmed that no documentation was present in the record for Residents #6 and #35 related to any written notifications for the transfers to the hospital. Review of a facility-provided policy titled 'Notice Requirements before Transfer/Discharge', dated (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 105323 Printed: 05/28/2026 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 105323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Clearwater, The 420 Bay Ave Clearwater, FL 33756 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 0623 08/26/2021 documented: Level of Harm - Minimal harm or potential for actual harm Intent: It is the policy of the facility to notify the resident and or their legal guardian of the before transfer and/or discharge according to state and federal regulations. Residents Affected - Some Procedure: 1. Before the facility transfers a resident to a hospital ., the nursing facility must provide written information to the resident or resident representative that specifies: ., B. Notify the resident and, if known, a family member or the resident's representative (s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Written Notice: 1. The notice will be in writing and will contain all information required by state and federal law, rules, or regulations applicable to Medicaid or Medicare cases. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 2 of 8 Printed: 05/28/2026 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 105323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Clearwater, The 420 Bay Ave Clearwater, FL 33756 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: 1. Review of the Electronic Medical Record (EMR) 'Face Sheet' revealed Resident #6 was originally admitted to the facility on [DATE]. Further review of the EMR Census Tab revealed Resident #6 was transferred to the hospital on [DATE]. Additional review of the EMR revealed a nurse progress note dated 08/29/21 at 07:39 documenting a telephone message left for Resident #6's spouse requesting a call back related to the transfer of Resident #6 to the hospital. No additional evidence was present in the clinical record related to the provision of bed hold information. 2. Review of the EMR 'Face Sheet' revealed Resident #35 was originally admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Additional review of the EMR revealed a skilled nursing facility to hospital transfer form dated 07/31/21 at 3:08 p.m., the form documented the reason for the transfer of Resident #35 to the hospital. The form also documented a telephone notification of Resident #35's emergency contact. No additional evidence was present in the clinical record related to the provision of bed hold information. On 09/09/2021 at 4:31 p.m. an interview with the Social Services Director (SSD) revealed that she did not provide any written notifications other than to the ombudsman when a Resident transferred to the hospital. A subsequent interview was conducted on 09/09/2021 at 4:40 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA stated they were not sending paperwork in the mail, she stated that nursing was sending some information with the resident to the hospital. The NHA confirmed that no documentation was present in the record for Residents #6 and #35 related to any notification of the bed hold policy. Review of a facility-provided policy titled 'Notice of Bed Hold Policy Before/Upon Transfer', dated 08/26/2021 documented: Intent: It is the policy of the facility to notify the resident and or their legal guardian of the Bed-Hold Policy according to state and federal regulations. Procedure: 1. Before the facility transfers a resident to a hospital ., the nursing facility must provide written information to the resident or resident representative that specifies: A. the duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. B. the reserve bed payment policy in the State plan ., if any, and C. at the time of the transfer .the facility will provide to the resident and the resident representative written notice, which specifies the duration of the bed-hold policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 3 of 8 Printed: 05/28/2026 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 105323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Clearwater, The 420 Bay Ave Clearwater, FL 33756 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some Findings included: Posted Staffing Data was observed on 09/08/21 at 2:45 P.M. at the Nurses' Station of the facility. The posting was dated 09/08/21; numbers of staff by discipline and shift were posted however the column titled 'actual hours' was blank. Photographic evidence was obtained. Posted Staffing Data was observed on 09/09/21 at 09:21 A.M. at the Nurses' Station of the facility. The posting was dated 09/09/21; numbers of staff by discipline and shift were posted however the column titled 'actual hours' was blank. Photographic evidence was obtained. During an interview conducted with the Nursing Home Administrator (NHA) on 09/09/21 at 12:29 P.M., the NHA stated staffing numbers are completed by the Staffing Coordinator and posted daily. The posting was reviewed with the NHA, and she confirmed no data was entered or posted relating to actual hours worked. The NHA stated 'actual hours' were completed the following day and the forms were stored in the NHA's office. A policy was requested related to posting staffing information; however, the NHA stated the facility did not have a policy relating to posting staffing information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 4 of 8 Printed: 05/28/2026 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 105323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Clearwater, The 420 Bay Ave Clearwater, FL 33756 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: A record review for Resident #13 revealed an admission date of 01/08/2021 and diagnoses that included Bipolar Disorder, Dementia, Major Depressive Disorder and Anxiety as per the admission face sheet. The 5-Day Minimum Data Set (MDS) dated [DATE] showed; Section C, Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment; Section I, diagnosis of Anxiety, Depression, Bipolar Disorder and Psychotic Disorder were all checked 'yes'; and Section N, antipsychotics, antianxiety and antidepressants were received during 7 of the past 7 days. Review of the Care Plan revealed a focus of: The Resident uses antipsychotic, anxiolytics, and antidepressant medications (initiated 01/20/2021), with interventions that included; administer psychotropic medications as ordered, monitor for side-effects and effectiveness Q [each] shift, monitor/document/report PRN [as needed] any adverse reactions of psychotropic medications , and monitor/record occurrence of target behavior symptoms A review of the Medication Administration Record (MAR) and the Physician Order Summary as of 09/08/2021 showed: - Olanzapine 5milligrams (mg) orally daily for bipolar disorder, with a start date of 06/19/2021 and an end date of 09/08/2021 - Olanzapine 2.5 mg orally daily for bipolar disorder, with a start date of 06/08/2021 - Trazadone 50mg orally daily for Depressive Disorder, with a start date of 08/19/2021 - Ativan 1mg orally twice daily for Anxiety, with a start date of 08/19/2021 - Ativan 0.5mg orally twice daily for Anxiety, with a start date of 08/19/2021 (representing 4 doses of Ativan daily) Further review of the MAR and the Treatment Administration Record (TAR) revealed no behavioral monitoring, or monitoring for medication side-effects, or effectiveness since the medication start dates. On 09/09/2021 at 12:03 P.M. an interview was conducted with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), and the Director of Nursing (DON). The DON stated behavior monitoring should be documented on the TAR within the Electronic Medical Record (EMR). A review of the TAR by the UM revealed no documentation of behavior monitoring. Further review of the EMR by the UM showed behavior monitoring under the Certified Nursing Assistant (CNA) task list. The UM was unable to state where monitoring for medication side effects would be documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 5 of 8 Printed: 05/28/2026 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 105323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Clearwater, The 420 Bay Ave Clearwater, FL 33756 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 0758 Level of Harm - Minimal harm or potential for actual harm A subsequent interview was conducted with the DON on 09/09/2021 at 12:14 P.M. She provided the CNA task list documentation of behavioral monitoring, which showed it was incomplete for all behaviors. The DON stated it was her expectation that behavioral monitoring was completed by the Nurse and not the CNAs. She also confirmed Resident #13 did not have any psychotropic medication side-effect monitoring, or consistent behavioral monitoring by the Licensed Nurse. Residents Affected - Few At 09/09/2021 at 2:54 P.M. Resident #13 was observed lying in bed and appeared to be resting. The Resident was groomed with no odors noted. An interview was attempted; however, the Resident refused. A telephone interview with the Consultant Pharmacist was attempted on 09/10/2021 at 10:21 A.M. A voicemail was received, and a message stated the mailbox was full and unable to accept new messages. A review of a facility-provided policy titled Psychotropic Therapy, and dated January 2009 revealed: 1. Each resident receiving an antipsychotic drug for organic mental disorders is monitored for: -Episodes of behavioral symptoms being treated and/or manifestation(s) of the disordered process. -Adverse reactions and side effects -Appropriateness of drug selection and dosage FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 6 of 8 Printed: 05/28/2026 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 105323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Clearwater, The 420 Bay Ave Clearwater, FL 33756 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. The findings included: 1. During the Initial Kitchen tour on 09/08/21 at 9:39 AM, the walk in refrigerator temperature was reading 46 degrees F on dial thermometer closest to the entrance of the refrigerator. The thermometer was not located in the warmest part of the refrigerator unit. Photographic evidence obtained. There was another dial thermometer further back in the walk in refrigerator on the same side that was reading 50 degrees F. Photographic evidence obtained. The refrigerator fans were operating at the time. There were no staff going into the walk in refrigerator at the time and the walk in was well stocked with food. The temperature log for the walk in refrigerator unit revealed that temperature taken earlier in the morning was 56 degrees F. Photographic evidence obtained. According to the Food & Dining Director, the temperature was taken at 7:00 AM. On a follow up visit to the kitchen, on 9/9/21 at 1:09 PM, the temperature of the walk in refrigerator thermometer close to the entrance read 46 degrees F. Photographic evidence obtained. There were no staff entering the walk in at the time. On 09/10/21 at 10:10 AM, the walk in refrigerator findings were discussed with the Food & Dining Director as well as the recent Pinellas County Health Department Inspection report for food safety conducted on 7/15/21. Although the inspection result on the report was satisfactory, one of the violations on the report , violation #3 indicated equipment unable to properly cold hold food. Observed walk in cooler holding food at 44F and higher. Photographic evidence obtained. The surveyor asked Food & Dining Director what was done about this and he said they've had the walk in refrigerator repaired three times since that inspection. The surveyor requested the walk in refrigerator service repair invoices to review and the facility policy on food storage. Review of the kitchen equipment service repair invoices revealed that none of the invoices included repair of the walk in refrigerator. Most recent invoice was for gas valve on 5/10/21 and 4/02/21 for the tilt skillet. On 09/10/21 at , the facility lead consultant dietitian stated that the facility did not have a policy on food storage. A few minutes later, he provide a food safety policy that was undated, but he said that it was the same date as the other policies provided, which were dated 1/26/2016. This policy documented: Purpose: To provide a safe environment for employees in the food service department. The [sic] provide food that is free from contamination thus risking the health and well being of residents and staff. To comply with DOH guidelines in the food service department. Procedure: . 5. Temperatures of food will be monitored . Photographic evidence obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 7 of 8 Printed: 05/28/2026 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 105323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Clearwater, The 420 Bay Ave Clearwater, FL 33756 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a follow up visit to the kitchen on 9/9/21 at 7:16 AM, as the breakfast service began, the holding temperatures were taken of the hot food to be served to the nursing home residents on the steam table. The nursing home breakfast trays were already being served and the temperatures were taken with the facility's digital thermometer by the morning cook, Staff B. Initially, the pureed sausage was found to be 120 degrees F on the first reading. After the cook, Staff B stirred the pureed sausage and took another temperature and it was 127 degrees F. The pureed sausage is Time/Temperature Control for Safety (TCS) food and a modified consistency food, which means the food was subjected to multiple food processes before consumption by residents. The surveyor asked the cook, Staff B what the minimum hot holding temperature was and he said 133 degrees F. At 7:20 AM, the cook, Staff B said that the the pureed sausage was put on steam table about 30 minutes ago. The food temperature log indicated that the pureed sausage was 165 degrees F when it was put in the steam table. Photographic evidence obtained. He removed the pan of pureed sausage and put it in the steamer first, but the Prep Cook, Staff C said it would heat up faster on the stove top. The cook, Staff B took the pureed sausage out of the steamer and put the pan on the stove top. The surveyor asked the cook, Staff B what the reheating temperature should be be and he replied that is should be 150 degrees F, then he said 160 degrees F, and finally he said 165 degrees F. He checked the reheating temperature of the pureed sausage and it went up to 165 degrees F before he put it back on to the steam table. On 09/10/21 at 10:10 AM and 10:17 AM, these findings were discussed with the Food & Dining Director. He stated that his CDM in training conducted kitchen sanitation audits every Monday. If there are issues, they send reports to the appropriate staff to correct. The surveyor requested these audits for review. The weekly audits were reviewed from 7/5/21 through 9/6/21, and included the following items to inspect: refrigerator & freezer logs complete, equipment in good shape, and food temp logs in use & complete. These audits did not address whether the food holding or storage temperatures maintained at 41 degrees F or below or 135 degrees or above. Photographic evidence obtained. 1/26/2016 The facility policy on food temperatures, approval date of (prior to Phase 1 implementation of the revised nursing home regulations), documented the following: Procedure: 1. Hot foods should be maintained at a minimum of 135 degrees F. 2. Cold foods should be maintained at a maximum of 41 degrees F. 3. If hot food falls below 135 degrees F, option is to reheat food to 165 degrees F. Photographic evidence obtained. 3. During a follow up visit to the kitchen on 9/10/21 at 9:56 AM, there were there were some 3 spatulas hanging over the 3 compartment sink that had nicked edges on the food contact surface and was no longer easily cleanable. There was another spatula that appeared to be burnt or had a permanent brown stain on a portion of the food contact surface and was also not easily cleanable. Photographic evidence taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 8 of 8

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
0741GeneralS&S Dpotential for harm
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
0623GeneralS&S Epotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0625GeneralS&S Epotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0732GeneralS&S Epotential for harm
F732 - Nurse Staffing Information
Post nurse staffing information every day.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the September 10, 2021 survey of OAKS OF CLEARWATER, THE?

This was a inspection survey of OAKS OF CLEARWATER, THE on September 10, 2021. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OAKS OF CLEARWATER, THE on September 10, 2021?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Properly select, install, inspect, or maintain portable fire extinguishes."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·September 10, 2021