A list of the most recent deficiencies for The Oaks of Clearwater. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-20 | 2023-10-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-20 | 2023-10-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-20 | 2023-10-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-20 | 2023-10-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-20 | 2023-10-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-20 | 2023-10-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-20 | 2023-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-20 | 2023-10-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-20 | 2023-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-20 | 2023-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-20 | 2023-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-10 | 2021-10-01 | N |
| 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. | Health | 2021-09-10 | 2021-10-01 | N |
| Post nurse staffing information every day. | Health | 2021-09-10 | 2021-10-01 | N |
| 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. | Health | 2021-09-10 | 2021-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-10 | 2021-10-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-09 | 2021-10-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-09 | 2021-10-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-17 | 2021-06-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-03-31 | 2021-04-23 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-03-31 | 2021-04-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-05 | 2020-03-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-02-05 | 2020-03-06 | N |
| Develop a communication plan. | Fire Safety | 2020-02-05 | 2020-03-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-05 | 2020-03-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-05 | 2020-03-06 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-05 | 2020-03-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-07 | 2020-03-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-07 | 2020-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-07 | 2020-03-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-07 | 2020-03-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-07 | 2020-03-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-07 | 2020-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-07 | 2020-03-04 | N |
| Keep all essential equipment working safely. | Health | 2020-02-07 | 2020-03-04 | N |
