Health inspection·April 18, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The nursing notes also revealed a late entry nursing note authored by Staff C, LPN, created on 4/18/25 at 11:31 a.m., with an effective date of 4/11/25 at 6:42 p.m. The note revealed: Late entry, April ,2024 (sic) at 1842 pm. Writer intervened as the nurse in charge upon assessing patient noticed slight discoloration of right hand, patient was also holding hand and saying she was in pain. Writer offered the patient Tylenol for pain management, however patient declined, writer then offered an ice pack, however patient refused and was upset and requested that this writer and nursing assistant leave the room. Writer and nursing assistant left the room as requested by patient. An interview was conducted with the Interim Director of Nursing (DON) and Interim Nursing Home Administrator (NHA), on 4/17/25 at 12:15 p.m. The DON stated she investigated the incident involving Resident #1, checked on the resident, and saw the physician ordered an x ray. The DON stated Resident #1 is alert and confused but does not like to be changed and when they put her in bed she complained of pain to her right hand. The DON stated she interviewed the nurse involved, but not the CNAs involved in the incident. She stated she should have interviewed the CNAs and she was waiting for them to get back to her, but they did not called her back. The NHA stated to the DON, I asked you to get a statement from the CNAs. The DON replied, I didn't get statements, they didn't get back to me. During the interview, the DON could not recall the CNAs names involved in the incident with Resident #1. The DON stated the nurse told her they were changing Resident #1, she had a push back, and she complained of pain in her right hand. The DON stated she didn't get the whole story and she could not determine if Resident #1 was injured or abused by the CNA and it is still an open investigation. An interview was conducted with Staff D, LPN Unit Manager (UM) on 4/17/25 at 1:09 p.m. Staff D, LPN UM, stated the event with Resident # 1 happened on a Friday night and she had a bruise from the incident, so he obtained an order for an x-ray. He stated he received a phone call around 6:30 p.m. or 6:45 p.m., on 4/11/25 from the 3-11 p.m. nurse, who told him, during care, Resident #1 was swatting at the CNAs and complained of pain on her hand. Staff D, LPN UM stated the CNA involved was Staff A, CNA and this occurred while she was trying to change the resident. He stated he texted the Director of Nursing (DON) following the incident to inform her. An interview was conducted with Staff C, LPN on 4/17/25 at 1:33 p.m. She stated she was assisting a patient in another room and then she was coming out of the other room she heard Resident #1 yelling get out leave me alone. She stated Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA were trying to change Resident #1 and she was swatting at them. Staff C, LPN stated, I don't know what she hit or what happened to her hand. She kept screaming her hand her hand. Staff C, LPN stated her nursing note on 4/11/25 should have documented the patient was screaming and fighting with a CNA, not a patient. Staff C, LPN stated she talked to Staff A, CNA, but did not talk to Staff B, CNA about what occurred. The staff member stated she tried to talk to Resident #1, however, she was irate and yelling in Greek. She stated she reached out to the provider to obtain an order for an X ray. A phone interview was conducted with Staff B, CNA, on 1/17/25 at 2:20 p.m. Staff B, CNA stated she was in the shower area with another resident and the resident's family member, when the family member told her she was hearing screams and someone yelling stop, get away. She stated she went into Resident 1#'s room and observed Resident #1 lying in her bed and Staff A, CNA, was trying to change her. She stated Resident #1 was yelling, telling Staff A, CNA to get away, and was flapping her arms at her. She stated Staff A, CNA grabbed Resident #1's hand in a gentle way and Resident #1 was crying. Staff B, CNA stated she told Staff A, CNA, to leave the room. She stated Resident #1 kept saying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 2 of 3 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 04/18/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff A, CNA hurt her hand as she continued to cry. Staff B, CNA stated nobody from the facility asked her to write a statement relating to the incident. A follow up interview was conducted with Staff C, LPN, on 4/17/25 at 4:24 p.m. She stated Resident #1 was telling them get out and when she entered the room, Resident #1 was crying and stated her hand was hurting. Staff C, LPN asked the resident what happened and the resident answered in Greek. Staff C, LPN asked Staff A, CNA, what happed and she stated she was trying to change Resident #1. Staff C, LPN asked Staff B, CNA about the incident and Staff B, CNA stated she was not sure if Resident #1 hurt her hand by swinging it or when they rolled the resident onto her side. Staff C, LPN informed Staff D, LPN Unit Manager of the incident. An interview was conducted with Staff E, MDS Coordinator, on 4/18/25 at 10:09 a.m. Staff E, MDS stated she saw the nursing note written by Staff C, LPN and contacted the Interim Administrator and the Interim DON on 4/12/25 in the morning. She stated she told then there was an issue and they need to look at the note in the chart for Resident #1. Review of an undated facility policy and procedure entitled Abuse, Neglect and Exploitation revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect, and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, is warranted when suspicion of abuse neglect or exploitation, or reports of abuse, neglect of exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation; . 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and /or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105323 If continuation sheet Page 3 of 3