Deficiencies (last 5 years)
Deficiencies (over 5 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
148% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 10
Date: Oct 2, 2025
Visit Reason
Routine inspection of Oaks of Clearwater nursing home to assess compliance with Medicare/Medicaid regulations including resident rights, safety, medication management, sanitation, and infection control.
Findings
The facility had multiple deficiencies including failure to provide Notice of Medicare Non-Coverage to residents, inadequate cleanliness and maintenance of resident equipment and environment, failure to obtain required PASARR screenings, unsafe access to a functioning stove, medication errors exceeding 5%, unsanitary kitchen conditions with pest issues, incomplete resident documentation, and lack of a water management plan for Legionella prevention.
Deficiencies (10)
F 0582: The facility failed to provide Notice of Medicare Non-Coverage (NOMNC) to three residents when Medicare-covered services terminated and lacked a policy for NOMNC notifications.
F 0584: Resident rooms, equipment, and shower rooms were not maintained in a clean and sanitary manner, with biogrowth on shower chairs and curtains, cracked and torn wheelchair armrests, and water leaks causing ceiling damage.
F 0644: The facility failed to obtain Level II PASARR screenings for two residents and lacked clarity on PASARR responsibilities among staff.
F 0689: The facility failed to ensure ambulatory residents did not have access to a functioning stove in an unlocked room and had unsafe handrails near the nursing station.
F 0756: The facility failed to address pharmacy recommendations for one resident regarding medication diagnosis and regimen review documentation.
F 0759: Medication error rate was 12.9%, exceeding the 5% threshold, including insulin pen misuse, failure to check vital signs before medication, and early administration of medications.
F 0812: The kitchen failed to meet sanitation requirements with pest infestations, bio-growth in drains, dirty and oxidized equipment, improperly stored food, and inadequate cleaning schedules.
F 0842: The facility failed to maintain accurate and complete documentation in the electronic medical record for one resident, including missing incontinence care records.
F 0880: The facility lacked a water management plan to assess and monitor for Legionella and other waterborne pathogens, with no documented Legionella testing or facility assessment.
F 0925: The facility failed to ensure an effective pest control program for small flying insects in the kitchen, with observed insect presence and lack of pest control policy.
Report Facts
Medication error rate: 12.9
Medication administration opportunities observed: 31
Medication errors identified: 4
Residents sampled for NOMNC provision: 3
Residents sampled for PASARR screening: 25
Residents observed with unsafe stove access: 3
Days of kitchen inspection with pest issues: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2025 with deficiency history and inspection statuses.
Findings
Across the inspections, the facility had a mix of deficiencies cited, corrected, and no deficiencies found, with numerous complaint investigations and monitoring visits over the years.
Report Facts
Inspections on page: 70
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to thoroughly investigate a grievance voiced by a resident's family member.
Complaint Details
The complaint was related to the facility's failure to investigate and document a grievance voiced by Resident #3's family member. The grievance involved concerns about care and the behavior of another resident. The complaint was substantiated as the facility did not file a grievance or conduct an investigation.
Findings
The facility failed to document or investigate a grievance raised by Resident #3's family member about care concerns. The Nursing Home Administrator did not file a grievance or provide documentation of an investigation, and grievance logs showed no record of the complaint.
Deficiencies (1)
F 0585: The facility failed to honor the resident's right to voice grievances without discrimination or reprisal and did not establish a grievance policy with prompt efforts to resolve grievances. The grievance raised by Resident #3's family member was not investigated or documented.
Inspection Report
Complaint
Deficiencies: 1
Date: Jul 23, 2025
Visit Reason
One Class 3 deficiency related to emergency management planning was found.
Findings
One Class 3 deficiency related to emergency management planning was found.
Deficiencies (1)
Tag ZZ830 — EMERGENCY MANAGEMENT PLANNING
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
The inspection was conducted to investigate alleged violations of abuse and mistreatment involving Resident #1, following reports of injury and complaints during care.
Complaint Details
The complaint investigation involved Resident #1 with alleged abuse and mistreatment. The investigation was still open at the time of the survey, with incomplete staff interviews and unclear conclusions regarding injury or abuse.
Findings
The facility failed to ensure a timely and thorough investigation of an injury of unknown origin for Resident #1. Interviews and record reviews revealed incomplete investigation steps, including failure to interview all involved staff and unclear determination of abuse or injury cause.
Deficiencies (1)
F 0610: The facility did not ensure an injury of unknown origin was thoroughly investigated in a timely manner for Resident #1. The investigation lacked interviews with all involved staff and did not conclusively determine if abuse or injury occurred.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Authored nursing notes documenting the incident and participated in interviews |
| Staff D | LPN Unit Manager (UM) | Managed incident follow-up and communicated with Director of Nursing |
| Staff A | Certified Nursing Assistant (CNA) | Involved in care during incident and alleged to have caused injury |
| Staff B | Certified Nursing Assistant (CNA) | Witnessed incident and participated in interviews |
| Interim Director of Nursing (DON) | Interim Director of Nursing | Conducted partial investigation and interviews |
| Interim Nursing Home Administrator (NHA) | Interim Nursing Home Administrator | Oversaw investigation and requested staff statements |
| Staff E | MDS Coordinator | Notified administration of issues found in nursing notes |
Inspection Report
Complaint
Deficiencies: 0
Date: Dec 7, 2024
Visit Reason
No deficiencies noted.
Findings
No deficiencies noted.
Inspection Report
Complaint
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
No deficiencies noted.
Findings
No deficiencies noted.
Inspection Report
Standard
Deficiencies: 9
Date: Dec 18, 2023
Visit Reason
Multiple Class 3 deficiencies related to medication assistance, staffing, and training.
Findings
Multiple Class 3 deficiencies related to medication assistance, staffing, and training.
Deficiencies (9)
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0086 — TRAINING - ADRD
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0160 — RECORDS - FACILITY
Inspection Report
Routine
Census: 52
Deficiencies: 12
Date: Sep 20, 2023
Visit Reason
Routine inspection of Oaks of Clearwater nursing home to assess compliance with regulatory standards including resident care, infection control, environment, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, maintain confidentiality of resident information, ensure a safe and homelike environment, accurate resident assessments, care planning, accommodations for visual impairment, nail care, respiratory care, food safety, infection control, and call light accessibility.
Deficiencies (12)
F 0550: The facility failed to ensure residents received a dignified dining experience, with delays in tray delivery causing some residents to watch others eat before receiving their meals.
F 0583: The facility failed to maintain confidentiality of Protected Health Information (PHI) by displaying sensitive resident information on bulletin boards and carts accessible to visitors and staff.
F 0584: The facility failed to maintain a safe, clean, and homelike environment in six resident rooms, including issues with ceiling tiles, air vent dust, bio-growth, water leaks, loose toilet rails, and unsafe electrical cords.
F 0641: The facility failed to accurately assess a resident's discharge status on the Minimum Data Set (MDS), incorrectly documenting discharge to an acute hospital instead of assisted living.
F 0644: The facility failed to refer three residents for Level II Pre-admission Screening and Resident Review (PASARR) upon significant change in mental health status.
F 0657: The facility failed to revise the person-centered care plan to reflect a resident's unique communication needs, specifically the use of the word 'mama' to express needs.
F 0676: The facility failed to ensure accommodations were in place for a visually impaired resident, resulting in difficulty identifying food and accessing call light and oxygen tubing.
F 0677: The facility failed to provide nail care, including trimming and cleaning fingernails, for one resident despite care plan requirements.
F 0695: The facility failed to ensure a resident was administered oxygen at the physician-ordered flow rate of two liters per minute, instead receiving one liter per minute.
F 0812: The facility failed to ensure food items in the kitchen walk-in refrigerator were labeled and dated, the refrigerator temperature log was completed daily, and the dishwasher was functioning properly.
F 0880: The facility failed to implement proper infection control practices for two residents on isolation precautions, including lack of PPE carts and staff not wearing required PPE.
F 0919: The facility failed to ensure call light systems were accessible to eleven residents and one resident bathroom lacked a call light pull cord, with many call lights out of residents' reach.
Report Facts
Residents affected: 6
Residents affected: 52
Residents affected: 32
Residents affected: 2
Residents affected: 11
Deficiencies cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in findings related to dignified dining and MRSA wound care |
| Staff B | Certified Nursing Assistant (CNA) | Named in findings related to dining tray delivery and resident communication |
| Staff C | Certified Nursing Assistant (CNA) | Named in findings related to dining tray delivery |
| Staff D | Dining Room Manager (DRM) | Named in findings related to food labeling and refrigerator temperature log |
| Staff E | Dietary Staff (DS) | Named in findings related to dishwasher malfunction |
| Staff F | MDS Coordinator (MDSC) | Named in findings related to discharge assessment error |
| Staff I | Licensed Practical Nurse (LPN) | Named in infection control findings for failure to wear PPE |
| Staff J | Certified Nursing Assistant (CNA) | Named in findings related to visual impairment accommodations |
| Staff K | Contracted Respiratory Therapist (CRT) | Named in findings related to oxygen administration |
| Assistant Director of Nursing/Unit Manager (ADON/UM) | Assistant Director of Nursing/Unit Manager | Named in multiple findings including infection control, care planning, and resident communication |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including infection control, care planning, and resident communication |
| Central Service Director (CSD) | Central Service Director | Named in findings related to housekeeping and maintenance issues |
Inspection Report
Complaint
Deficiencies: 10
Date: Dec 29, 2022
Visit Reason
Multiple Class 3 deficiencies related to admissions, resident care, training, records, and background screening.
Findings
Multiple Class 3 deficiencies related to admissions, resident care, training, records, and background screening.
Deficiencies (10)
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Tag A0034 — ASSISTIVE DEVICES
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0086 — TRAINING - ADRD
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0162 — RECORDS - RESIDENT
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Inspection Report
Complaint
Deficiencies: 1
Date: Jun 27, 2022
Visit Reason
One Class 3 deficiency related to resident care rights and facility procedures.
Findings
One Class 3 deficiency related to resident care rights and facility procedures.
Deficiencies (1)
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
Inspection Report
Standard
Deficiencies: 6
Date: Jan 7, 2022
Visit Reason
Multiple Class 3 deficiencies related to staffing, training, records, and limited nursing services.
Findings
Multiple Class 3 deficiencies related to staffing, training, records, and limited nursing services.
Deficiencies (6)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0086 — TRAINING - ADRD
Tag A0162 — RECORDS - RESIDENT
Tag AN277 — LNS - RESIDENT CARE STANDARDS
Tag AN278 — LNS - RECORDS
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Inspection Report
Routine
Deficiencies: 5
Date: Sep 10, 2021
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations related to resident transfer/discharge notifications, bed hold policies, nurse staffing postings, psychotropic medication monitoring, and food safety standards.
Findings
The facility failed to provide timely written notifications to residents or their representatives regarding transfers and bed hold policies for two residents. Staffing information postings lacked actual hours worked on two of three days observed. Behavioral monitoring related to psychotropic medications was incomplete for one resident. Food safety violations included improper cold and hot food holding temperatures and unclean kitchen utensils.
Deficiencies (5)
F 0623: The facility failed to provide timely written notification to residents or their representatives before transfer or discharge for two residents.
F 0625: The facility failed to provide written documentation of the bed hold policy to residents or their representatives for two residents.
F 0732: The facility failed to post nursing staffing information including actual hours worked on two of three days observed.
F 0758: The facility failed to ensure behavioral monitoring related to psychotropic medications was performed for one resident reviewed for unnecessary medications.
F 0812: The facility failed to maintain cold food at 41°F or below, hot food at 135°F or above, and maintain kitchen utensils in good condition.
Report Facts
Deficiencies cited: 5
Temperature readings: 46
Temperature readings: 50
Temperature readings: 56
Temperature readings: 120
Temperature readings: 127
Temperature readings: 165
Medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse, Unit Manager | Interviewed regarding behavioral monitoring for psychotropic medications |
| Staff B | Morning Cook | Provided information and took temperatures during food service observations |
| Staff C | Prep Cook | Assisted with reheating food during kitchen observations |
| Social Services Director | Interviewed about written notifications for resident transfers | |
| Nursing Home Administrator | Interviewed about transfer notifications and staffing postings | |
| Director of Nursing | Interviewed about transfer notifications and behavioral monitoring |
Inspection Report
Standard
Deficiencies: 1
Date: May 20, 2021
Visit Reason
One Class 3 deficiency related to staff records.
Findings
One Class 3 deficiency related to staff records.
Deficiencies (1)
Tag A0161 — RECORDS - STAFF
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