Clearwater Healthcare Center

In the surveyor’s words

From the most serious findings on record at Clearwater Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF760Jan 17, 2025

  Based on interview, and record review, the facility failed to ensure safe medication use and practices when one of the three sampled residents (Resident 1) received duplicate blood thinner medications concurrently (drugs with potential to cause significant internal bleeding) for 3.5 days after admission to the facility, and failed to seek clarification before continuing with the blood thinning therapy after identified the error on [DATE]. These failures resulted in Resident 1 having a critically high Prothrombin Time/International Normalized Ratio (PT/INR: blood tests used to measure bleeding and clotting times- high levels indicate blood takes longer to clot) and Resident 1 was transferred to the Emergency Department (ED) at Hospital B on [DATE], suffered complications that included… […]

• No harm, potential for more than minimal, widespreadF925Mar 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure it maintained effective pest control services for a census of 115 where 107 residents received facility prepared meals when a live baby cockroach was crawling on a clean colander on the shelf next to the stove in the kitchen. This failure had the potential to spread a variety of diseases and bacteria throughout the facility to its residents, staff, and visitors. Findings: During a concurrent observation and interview on 3/25/25, at 11 a.m., with the Food Services Director (FD) in the kitchen, the following findings were observed and confirmed by the FD: a. A pot on the stove that had a thick, brownish gummy substance on the bottom and sides was being used to prepare lunch for the facility residents. b. […]

• No harm, potential for more than minimal, widespreadF755Oct 27, 2023

  Based on observation, interview and record review, the facility failed to follow facility policy and standards of practice for medication administration for five of five residents, (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) when four of four licensed nurses (LN), LN 2, LN 3, LN 4, and LN 5, failed to sign off medications at the time of administration. This failure had the potential to result in medication errors for all residents receiving medications in the facility. Findings: a. During a concurrent observation, interview, and record review with LN 2, on 10/10/23, at 11:49 AM, LN 2 was passing medications and the Electronic Health Record (EHR) displayed the residents' names in a box. The boxes were highlighted in red. […]

• No harm, potential for more than minimal, patternF812Jul 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared safely and kitchen equipment and food contact surfaces were maintained in a clean and sanitary condition for 102 residents who consumed facility-prepared meals when:1. Staff personal items were not stored appropriately to prevent potential contamination of food storage area;2. Frozen breaded pork patties were not thawed using approved thawing methods;3. The resident refrigerator was not maintained within an acceptable temperature range for food storage, and the freezer compartment did not have a thermometer to monitor the temperature;4. The can opener sleeve/holder was not maintained in a clean and sanitary condition;5. […]

• No harm, potential for more than minimal, patternF686Apr 23, 2025

  Based on observation, interview, and record review, the facility failed to implement the repositioning (turning) intervention to prevent pressure ulcer/injury (PU - areas of damaged skin typically caused by staying in one position for too long), for 4 of 5 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) who were assessed at risk for PU development. This failure had the potential for pressure ulcers to develop for Resident 1, Resident 2, Resident 3, and Resident 4. Findings: 1. […]