Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oaks Of Clearwater, The during CMS and state inspections, most recent first.
Kitchen sanitation and food storage deficiencies: During repeated tours, the CDM and surveyors observed flying insects around the handwashing sink, bio-growth in the drain area, an oxidized and leaking dish machine with debris on the floor, dirty and oxidized walk-in cooler/freezer surfaces, unlabeled and exposed frozen poultry, dust and debris over food service equipment, bio-growth on an ice maker used for resident food, and a full used cooking oil container leaking onto the parking lot. The CDM stated several areas had recent maintenance, was unaware of some conditions, and the NHA reported no QAPI plans related to dietary services.
Missing Water Management Plan for Legionella Monitoring: The facility did not ensure a water management plan was in place to assess, identify, and monitor for Legionella and other opportunistic waterborne pathogens. When asked for the plan, staff provided a water treatment invoice and a chilled loop service report that documented pH, conductivity, iron, alkalinity, and sodium nitrate testing, but no documentation of Legionella or other waterborne pathogen testing. The DON and RDOM could not confirm that such testing had been done, and the facility could not provide its Legionella facility assessment.
Surveyors observed multiple sanitation and maintenance issues throughout the facility, including cracked and torn wheelchair armrests, a missing armrest pad, commode and toilet surfaces with non-cleanable buildup, shower chairs and privacy curtains with biogrowth, dusty ceilings, and ceiling vents with black biogrowth and dripping water. Staff interviews confirmed unclear responsibility for cleaning shower equipment and no documented policy for housekeeping or wheelchair maintenance, while the NHA acknowledged the lack of documentation assigning those duties.
Pest Control Program Not Effective in Kitchen: Small flying insects were observed around the hand washing sink, floor drain, and food prep/food service areas, with dietary staff swatting at them and no one knowing the source. The CDM said the outside pest control vendor treated the facility regularly, but he did not know the last service date, and the maintenance director had no recent pest work orders, was unaware of a clogged drain near the sink, and could not provide a pest control policy or procedure.
Failure to Issue NOMNC for Medicare Skilled Service Terminations: The facility did not provide NOMNCs to three residents or their designated representatives when Medicare Part A skilled services ended. Records showed one resident with severe cognitive impairment, one with moderate thinking and memory problems and a POA, and one with metabolic encephalopathy and acute respiratory failure with hypoxia. The Social Service Director stated the NOMNCs did not exist and no copies were found in the EHR.
Failure to Obtain Level II PASARR Evaluations: The facility did not obtain Level II PASARR evaluations for two residents with extensive psychiatric and cognitive diagnoses. One resident had schizoaffective disorder, dementia with psychotic disturbance, anxiety, depression, and recent transfer for auditory hallucinations and mental health evaluation; the other had Lewy body neurocognitive disorder, schizoaffective disorder, anxiety, depression, and alcohol dependence in remission. Interviews showed staff were unclear who was responsible for PASARRs, and the record did not show the required Level II reviews were completed.
A resident with Lewy Body dementia, alcoholism history, and multiple psychiatric diagnoses had an inaccurate PASARR Level I screen that found no SMI or ID and no need for Level II review. Later records showed diagnoses including schizoaffective disorder, anxiety, depression, and mood disorder, while staff gave conflicting accounts of who completed PASARRs: SSD said nursing did them, the Unit Manager said Social Services did them, and the NHA said the DON was responsible but was unsure about system access.
Accessible Stove Area and Unsafe Handrail: An unlockable activity/dining room contained a functioning four-burner glass top stove, and ambulatory residents were observed entering the room, including residents with moderate cognitive impairment. Staff described the room as used for activities and dining, and the NHA later confirmed the stove heated up and that residents could have burned themselves. A separate observation found a handrail next to the nursing station with missing curved ends and exposed metal brackets, which the NHA agreed could injure a resident.
Failure to Address Pharmacy Medication Review Recommendations: The facility failed to address pharmacy recommendations for a resident receiving rifaximin for an unsupported diagnosis. The DON and NHA could not provide complete pharmacy recommendation records for the requested period, and the available recommendation for the resident showed an undated pharmacist note questioning the diagnosis for Xifaxan with an illegible prescriber response.
Medication administration errors exceeded the allowed rate after multiple observed errors involving an LPN and three residents. One resident received insulin lispro from a Kwik pen that was not primed, another received carvedilol without the required BP check before administration, and a third resident received buspirone and morphine before the scheduled time. The DON and unit staff acknowledged the errors, and the resident record for the early medications did not show physician notification.
Incomplete EMR documentation was identified for a resident with dementia, impaired mobility, and frequent incontinence. The CNA Kardex had missing incontinence charting on multiple occasions, and CNAs, LPNs, and the DON stated care should be documented each shift or at the time of service; the facility policy required accurate, complete, and timely documentation.
A resident's family member raised concerns about care and was unable to reach the NHA by phone, communicating instead via text. The family member described the NHA as dismissive and received no follow-up or information about the outcome. Despite facility policy requiring all concerns to be documented and investigated as grievances, no grievance was filed or investigated, and no documentation was made regarding the concern.
A resident with severe cognitive impairment and a history of psychiatric and neurological conditions was found with multiple bruises and reported pain after resisting care. The facility did not conduct a timely or thorough investigation, as the DON failed to interview all involved CNAs or obtain their statements, leaving the incident unresolved and not fully documented, contrary to facility policy.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to ensure the kitchen met sanitation requirements during repeated kitchen observations over three days. During tours with the Certified Dietary Manager (CDM), the handwashing sink area had no garbage can readily accessible for used paper towels, and approximately eight small flying insects were observed around the sink, walls, floor, and drain area. The CDM stated they were not aware of any issues causing the insects and did not notice them until it was brought to attention. The kitchen’s floor drain next to the handwashing sink had several soiled plastic pipes and a drain plate covered with a thick clear, gray, and orange gelatinous substance that appeared to be bio-growth. In the dishwashing machine room, the large high-temperature dishwashing machine had a reddish-brown flaky surface, oxidized white and green areas on the doors, and a clear liquid squirting from the top left corner onto the oxidized area. The floor under and in front of the machine had calcification, oxidation, and built-up debris. The CDM stated the machine was very old, had recent maintenance, and the facility was trying to get another one. Additional observations showed the walk-in refrigerator floor had debris and dirt-like substances, oxidized corners, and build-up on surfaces, and the CDM did not have a cleaning schedule for the unit. Several round containers in the walk-in refrigerator held unidentified liquid food products with spilled product on the outside of the containers. The walk-in freezer had icing on the ceiling with icicles about six inches long, large chunks of ice on the floor and in mat holes, and an opened brown box lined with a blue plastic bag containing frozen turkey legs/chicken legs that were exposed, unlabeled, and frosted over. Other kitchen areas included a standing fan with dust and debris pointed into the food preparation area, a steam table with chains covered in dust and debris hanging over exposed food, shelves with dust, debris, and oxidation, a food warmer with a dark brown or black substance leaking down the wall, a heating table with discoloration and grease-like substances, a freezer with papers and debris on the floor, dark substances on floors and walls, and a freezer door with jagged metal sticking out. An ice maker on the second floor used for resident food had gelatinous green and purple bio-growth and ice buildup on the tray, and the CDM could not determine who was responsible for its maintenance. Outside, the used cooking oil container was full and placed on an outlined catch container that was also full, with oil leaked onto the parking lot and a foul odor present. The CDM stated the oil was emptied by an outside company and believed it was emptied about weekly. The facility policy required food service areas to be kept clean, sanitary, and free from litter, rubbish, rodents, roaches, flies, and other insects, with daily and weekly sanitation inspections, but the NHA stated there were no performance improvement plans related to kitchen or dietary services.
Missing Water Management Plan for Legionella Monitoring
Penalty
Summary
Provide and implement an infection prevention and control program. Based 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. When asked to provide the water management plan, the facility instead provided a water treatment contract invoice and a service report dated 7/7/25. The service report documented quarterly service for the chilled loop, including testing of pH, conductivity, iron, alkalinity, and sodium nitrate, but it did not include documentation of testing for Legionella or other waterborne pathogens. During an interview on 10/2/25 at 1:02 p.m., the RDOM and DOM stated the DOM had been in the position for two weeks and initially did not know whether the facility had a water treatment plan. The Regional DOM stated the facility had recently changed water treatment companies and had a signed agreement, but the company had not yet conducted its first water treatment. The Regional DOM reviewed the 7/7/25 service report and could not confirm whether the water was tested for Legionella and other waterborne pathogens. The facility was unable to provide its Legionella facility assessment. Facility policies titled Legionella Surveillance and Legionella Water Management Program, along with a document titled Water Management Program, stated that the facility had a water management program overseen by a water management team and that it included identifying areas where Legionella or other waterborne bacteria could grow and spread.
Failure to Maintain Clean and Sanitary Resident Areas and Equipment
Penalty
Summary
The facility failed to maintain resident rooms, resident equipment, and shower room equipment in a clean and sanitary condition during observations on 9/30/2025, 10/1/2025, and 10/2/2025. During facility-wide tours, surveyors observed resident wheelchair armrests that were cracked, torn, or missing, resident rooms that were soiled, toilet devices and shower chairs that were not sanitary, and visible biogrowth on equipment and surfaces. In the main community shower room, two plastic shower chairs were observed wet and appearing recently used, and one white plastic shower chair had heavy black and pink biogrowth on the legs, wheel castors, and pivot areas, with dark black biogrowth on the backing and fabric. Three privacy curtains in the shower room were also observed with spotty dark areas and lined black biogrowth near the bottom half. In resident rooms, surveyors observed multiple wheelchairs with cracked and torn armrests, a wheelchair missing a right-side armrest pad, a commode device with a brittle reddish-brown flaky coating on the metal surface, and a toilet lid with a painted surface scraped off leaving a non-cleanable surface. One room ceiling had heavy dust and debris near the ceiling vent, and another room had a ceiling vent with heavy black biogrowth and paint chipping and cracking. The resident in the room with the missing armrest pad stated it would be better and more comfortable to have one, and another resident stated his wheelchair was terrible and that he had notified staff to replace the armrests. Additional observations included ceiling vents in the North and South dining/activity rooms that were constantly dripping water onto the floor, and peeling wall covering along the East hallway handrails. Interviews with the Housekeeping Director, Maintenance Director, and Nursing Home Administrator confirmed housekeeping was responsible for day-to-day cleaning, nursing staff were responsible for cleaning shower chairs after use, maintenance handled wheelchair maintenance, and the facility did not have a general housekeeping or wheelchair maintenance policy and procedure. The NHA also stated there was no documentation showing who was responsible for cleaning shower room equipment or for the general maintenance of resident rooms and resident equipment.
Pest Control Program Not Effective in Kitchen
Penalty
Summary
The facility failed to ensure an effective pest control program related to small flying insects in the kitchen. On 9/30/2025 at 9:18 a.m., during a kitchen tour with the Certified Dietary Manager (CDM), several small flying insects were observed at the hand washing sink, with approximately eight insects flying around and landing on the walls, paper towel dispenser, sink, and floor. The floor drain with a metal plate also had gelatinous bio growth on it. The CDM stated he had not noticed the insects before they were pointed out and confirmed there were more than a few insects in the area, but did not know how long they had been present. On 10/1/2025 at 11:15 a.m. and 1:30 p.m., small flying insects were again observed in the area of the hand washing sink and floor drain, as well as in the food preparation and food service areas of the kitchen. Dietary staff were observed swatting at the insects, and none knew where they were coming from. The CDM stated the facility had an outside pest control company that came monthly for general treatment and more frequently for outbreaks, but he did not know the last treatment date. The maintenance director stated staff were trained to use the electronic work order system to report pests and that he checked it daily, but he had no current work orders from the past week and was unaware of any backed up or clogged drain near the kitchen hand washing sink. He provided pest control treatment reports dated 5/20/2025, 6/17/2025, 8/18/2025, and 9/16/2025 for flying insects, but the reports did not specify the treated areas. The facility contract showed weekly pest control maintenance and monthly exterior treatment, but the contract did not specify treatment for small flying insects, and the maintenance director was unable to provide a pest control policy and procedure.
Failure to Issue NOMNC for Medicare Skilled Service Terminations
Penalty
Summary
The facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was provided to notify residents when Medicare-covered skilled services would terminate and to inform them of the right to appeal the decision. Record review showed that Resident #31 had a Medicare Part A skilled services episode that started on 02/18/2025 and ended on 04/16/2025, Resident #40 had a Medicare Part A skilled services episode that started on 03/01/2025 and ended on 04/17/2025, and Resident #55 had a Medicare Part A skilled services episode that started on 03/29/2025 and ended on 04/16/2025. Review of the electronic health record on 10/02/2025 showed no NOMNC for any of these residents, and no documentation that the notice had been issued to the resident or the designated representative. Resident #31’s record showed an admission in 11/2024 and a readmission on 02/18/2025, with a family member designated as responsible party; the most recent quarterly MDS dated 08/23/2025 showed a BIMS score of 6 with severe memory and orientation problems. Resident #40’s chart showed a family member designated as POA, diagnoses of spinal stenosis and cognitive communication deficit, and a quarterly BIMS score of 12 indicating moderate problems with thinking and memory. Resident #55’s chart showed a family member listed as emergency contact and diagnoses of metabolic encephalopathy and acute respiratory failure with hypoxia. During interview on 10/02/2025 at 10:57 a.m., the Social Service Director stated the NOMNC for the three residents did not exist and that no copy was found in the electronic health record. The facility did not provide a policy or procedure for NOMNC notifications.
Failure to Obtain Level II PASARR Evaluations
Penalty
Summary
The facility failed to obtain Level II PASARR evaluations for two residents with significant psychiatric and cognitive histories. Resident #8 had diagnoses including bipolar type schizoaffective disorder, severe unspecified dementia with psychotic disturbance, anxiety disorder, epilepsy, depression, and mood disorder. The record showed a prior Level I PASARR completed at the facility that found no Level II evaluation was required, but later records documented transfer to an acute care facility for auditory hallucinations and a mental health evaluation, along with psychiatric notes describing chronic schizoaffective disorder, paranoia, delusional thinking, acute mental status changes, and multiple psychiatric hospitalizations. Resident #9 had diagnoses including neurocognitive disorder with Lewy bodies, cognitive communication deficit, unspecified schizoaffective disorder, generalized anxiety disorder, major depressive disorder, alcohol dependence in remission, and mood disorder. The resident’s earlier PASARR from a rehabilitation hospital showed alcoholism and a history of Lewy body dementia, with no diagnosis or suspicion of SMI or ID and no Level II evaluation required at that time. The resident was later admitted and readmitted with the updated diagnoses noted in the record, but the clinical record did not show that a Level II PASARR had been obtained. During interviews, the SSD stated they did not do PASARRs at the facility and said nursing, specifically the Unit Manager, did them. The Unit Manager stated they did not do PASARRs and said Social Services did them. The NHA reported the DON was responsible for PASARRs but did not know whether the current DON had access to the PASARR system. Review of the facility policy stated the Social Services Director was responsible for tracking PASARR status and referring to the appropriate authority, and that residents with newly evident or possible serious mental disorder, intellectual disability, or related condition, including those admitted or readmitted after an inpatient psychiatric stay, would be referred promptly for Level II resident review.
Inaccurate PASARR Screening for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to obtain an accurate PASARR for one resident with a history of alcoholism and Lewy Body dementia. The resident’s original PASARR Level I screening, completed by a rehabilitation hospital, indicated no diagnosis or suspicion of SMI or ID and no Level II evaluation was required. However, the resident’s record later showed diagnoses including neurocognitive disorder with Lewy bodies, cognitive communication deficit, unspecified schizoaffective disorder, generalized anxiety disorder, unspecified single episode major depressive disorder, alcohol dependence in remission, and unspecified mood disorder. The resident’s psychiatric note also documented generalized anxiety disorder, recurrent severe major depressive disorder without psychotic features, unspecified schizoaffective disorder, and alcohol dependence in remission, and stated that a GDR was not to be attempted because it was clinically contraindicated. During interviews, the SSD stated they did not do PASARRs at the facility and said nursing, specifically the Unit Manager, completed them. The Unit Manager stated they did not do PASARRs and said Social Services did them. The NHA reported the DON was responsible for PASARRs but was unsure whether the current DON had access to the PASARR system.
Accessible Stove Area and Unsafe Handrail
Penalty
Summary
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. On 10/1/25, an observation of the southwest room found the door could be unlocked and the room contained a working stove; when a knob was turned on, one burner turned red and emitted heat. Staff stated the room was used for resident activities, luncheons, and sometimes quiet time with families, and the Nursing Home Administrator later stated the door had not been shut and initially believed the stove did not work. The administrator then demonstrated the stove becoming red with heat and acknowledged the residents could have burned themselves. Residents #23, #39, and #45 were observed using the area. Resident #23 ambulated into the northwest common/dining room and stated the northwest room was for independent diners and the southwest room was for dependent residents. Resident #39 was observed propelling self in and out of the southwest common/dining room, and Resident #45 was observed propelling self into the southwest common/dining room and reported coming into the room sometimes. Review of records showed Resident #23 had intact cognition with a BIMS score of 15/15, while Residents #39 and #45 had moderate cognitive impairment with BIMS scores of 9/15 and 8/15, respectively. The facility also failed to ensure safety of a handrail next to the nursing station, where an observed 3-4 foot section had missing curved ends and exposed silver metal brackets; the NHA agreed a resident could injure themselves on the exposed areas.
Failure to Address Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations for one resident sampled for unnecessary administration of medications. Resident #9 was observed sitting in a wheelchair in the room with the television on and responded to introduction with nonsensical speech. Review of the resident’s active orders showed rifaximin (Xifaxan) ordered for a diagnosis of other symbolic dysfunctions. The DON stated that the facility had only one pharmacy recommendation for another resident and was still looking for the remaining requested recommendations. The NHA stated the facility was waiting for pharmacy to send the pharmacy recommendation policy and later provided July, August, and September pharmacy recommendations, but the documents did not include all requested residents and did not show that pharmacy recommendations had been made during the requested times or that pharmacy had reviewed the medications to determine whether recommendations were needed. A pharmacy recommendation obtained for Resident #9 showed a recommendation printed on 8/29/25 asking the physician to consider changing the diagnosis for Xifaxan from other symbolic dysfunctions to other irritable bowel syndrome because the FDA had not labeled other symbolic dysfunctions as an approved indication for the medication. The recommendation showed the prescriber response as diagnosis changed to anxiety on 09/18/25 and signed illegibly, and the recommendation was not dated.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5.00%. During 31 observed medication administration opportunities, four errors were identified involving three residents, resulting in a 12.9% medication error rate. The observations and record reviews showed errors related to insulin pen use, failure to follow blood pressure parameters before administering carvedilol, and administration of medications outside the ordered time frame. For one resident, an LPN administered 8 units of insulin lispro using a Kwik pen after checking the blood glucose level, but the pen was not primed before use. The nurse stated she had been educated on insulin pen use but was not sure about priming the pen. The DON later stated awareness that the insulin pen had not been primed and commented on the nurse's lack of knowledge regarding priming. For another resident, an LPN gave carvedilol without first obtaining the resident's blood pressure, despite parameters on the medication profile and physician order to hold the medication for SBP less than 110, DBP less than 60, or heart rate less than 60. After being questioned, the nurse checked the order, obtained a blood pressure of 130/72 and pulse of 55, and then held the medication. For a third resident, an LPN administered buspirone and morphine earlier than the scheduled 9:00 a.m. time; the nurse confirmed both medications were not due until 9:00 a.m. The resident also received multiple other medications during the same observation, and the progress note did not document that the physician was notified of the early administration.
Incomplete EMR Documentation for Incontinence Care
Penalty
Summary
Documentation in the Electronic Medical Record was inaccurate and incomplete for one resident with muscle wasting and atrophy, difficulty walking, generalized anxiety disorder, and dementia. The resident’s MDS showed a Brief Interview Mental Status score of 09, indicating moderately impaired cognition, required supervision or touching assistance, required partial or moderate assistance for toilet transfers, and was incontinent frequently. Review of the CNA Kardex showed missing incontinence documentation on multiple dates in September 2025. During interviews, CNAs and LPNs stated incontinence care should be documented each shift, at the time of service, or by the end of the shift, and that if it was not documented, it did not happen. Staff also stated there was no paper charting and all charting was electronic. The DON stated charting should be completed at the time of service or at the end of the shift, and if it is not documented, it did not happen. The facility policy required documentation to be accurate, complete, and timely, and to be completed at the time of service or no later than the shift in which the care occurred.
Failure to Investigate and Document Family Grievance
Penalty
Summary
The facility failed to thoroughly investigate and document a grievance voiced by a resident's family member regarding concerns about the care provided. The family member reported being unable to reach the Nursing Home Administrator (NHA) by phone and communicated concerns via text message, but described the NHA as dismissive. The family member stated that after raising concerns, she did not receive any follow-up or information about what actions, if any, were taken by the facility. Review of the resident's medical records showed the resident had diagnoses including a wedge compression fracture of the vertebra and depression, and was admitted and later discharged from the facility within the review period. Interviews with facility staff, including the Social Services Director and the NHA, revealed that no grievance was documented or investigated regarding the family member's concerns, despite facility policy requiring all concerns to be treated as grievances and properly documented. The grievance logs for the relevant month contained no entries related to the resident in question. The NHA acknowledged receiving the concern but did not file a grievance or document any investigation, stating that a concern is not considered a grievance unless it occurs more than once, which is inconsistent with the facility's written grievance policy.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly and promptly investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses. The resident, who required substantial assistance for toileting and was at risk for skin tears and bruising, was observed with multiple bruises and a bandage above her right eye. She reported a fall as the cause of her facial bruise but could not recall how she injured her hand. Nursing notes documented an incident where the resident was resisting care, was in pain, and had discoloration on her right hand, but declined pain medication and ice. The investigation into the incident was incomplete. The DON stated she checked on the resident and saw that an x-ray was ordered, but only interviewed the nurse involved and not the CNAs who were present during the incident. The DON could not recall the names of the CNAs involved and did not obtain their statements, despite being asked to do so by the NHA. Staff interviews revealed that the resident was swatting at staff during care, complained of pain, and was observed crying, but there was inconsistency in staff recollection and documentation of the event. One CNA stated she was never asked to provide a statement about the incident. Facility policy required immediate and thorough investigation of alleged abuse, neglect, or injuries of unknown origin, including identifying and interviewing all involved persons and documenting the investigation. However, the facility did not follow these procedures, as not all involved staff were interviewed or provided statements, and the investigation remained incomplete at the time of the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clearwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gulfside Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Morton Plant Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Clearwater Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Highland Pines Rehabilitation Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Belleair Health Care Center | 1.9 mi | ★★★★★ | 27 | 0 |
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