Clearwater Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF600Jun 3, 2024

  The facility reported a census of 43 residents with 15 residents sampled, which included two residents reviewed for behaviors and resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse, when Resident (R)22, who had a history of hitting other residents, continued to hit residents in the facility on multiple occasions. On 12/20/22, R22 grabbed R195's sweatshirt by the collar and pushed her wheelchair backwards. R22 let go and then grabbed her nose between his index and middle finger. He continued to pull on her nose, which according to R195, caused pain. On 01/01/23, R22 hit R 196. […]

• Immediate jeopardy, widespreadF609Jun 3, 2024

  The facility reported a census of 43 residents with 15 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure the timely reporting of alleged abuse to the State Agency (SA - a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required. The facility failed to report two allegations of resident-to-resident abuse, when on 05/12/24 at 04:45 PM, R22, who had a history of hitting others, punched R17 on the left side of R17's jaw. On 05/20/24, R22 raised his closed fist to R2 and made contact with R2's face. […]

• Immediate jeopardy, widespreadF610Jun 3, 2024

  The facility reported a census of 43 residents with 15 residents sampled, which included two residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to investigate all allegations of resident-to-resident abuse to protect residents from further incidents of abuse. The facility failed to thoroughly investigate two abuse allegations regarding R22, who had a history of hitting other residents, and continued to hit residents in the facility on multiple occasions. On 12/20/22, R22 grabbed R195's sweatshirt by the collar and pushed her wheelchair backwards. R22 let go and then grabbed her nose between his index and middle finger. He continued to pull on her nose, which caused R195 pain. On 01/01/23, R22 hit R196. […]

• Immediate jeopardy, patternF689Jun 3, 2024

  The facility reported a census of 43 residents, with 15 included in the sample. Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when the hot water in four resident rooms and a beauty shop measured at hazardous levels ranging between 138 and 157 degrees Fahrenheit (F). This failure affected six residents (Resident (R) 3, R15, R19, R22, R29, and R30) two of which were cognitively impaired and independently mobile, and any resident who received services in the beauty shop rinse sink. This failure placed the residents in immediate jeopardy to their health and safety and at risk for burns and injury related to hot water exposure. […]

• Immediate jeopardy, isolatedF689Jun 3, 2026

  Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R)14, who the facility identified as at high risk for wandering. On 05/15/2026 at approximately 11:35 AM, R14 exited the unsecured smoking area in the facility parking lot after Certified Nurse Aide (CNA) M turned to assist another resident. At approximately 01:43 PM, Dietary Staff BB went to R14's room to pick up his lunch tray and identified that the resident was not in his room and had not eaten lunch. Dietary Staff BB notified other staff, and they began searching for R14 at 01:45 PM. At approximately 02:04 PM, staff located R14 approximately 0.8 miles from the facility and returned him to the facility without injuries. […]