Oaks of Clearwater, The

In the surveyor’s words

From the most serious findings on record at Oaks of Clearwater, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Oct 2, 2025

  Based on observations, record reviews, and interviews, the facility failed to ensure the kitchen met sanitation requirements for one kitchen of one during 3 days (09/30/2025, 10/01/2025 and 10/02/2025) of three days observed.Findings included: During kitchen tours conducted with the Certified Dietary Manager (CDM), on 9/30/2025 at 9:25 a.m., on 10/1/2025 at 11:15 a.m. and 1:16 p.m., the following observations were made.Upon entering the kitchen, there was no garbage can readily accessible to dispose used paper towels after washing hands. The CDM revealed they did have one but was not sure where it went. […]

• No harm, potential for more than minimal, widespreadF880Oct 2, 2025

  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. Findings include: The facility was asked to provide their water management plan. On 10/2/25 at 11:30 a.m., the facility provided a water treatment contract invoice and a service report dated 7/7/25. Further review of the report revealed it was the quarterly service for the chilled loop which included testing of the pH (power of hydrogen measuring acidity of alkalinity), conductivity, iron, alkalinity, and sodium nitrate. […]

• No harm, potential for more than minimal, patternF584Oct 2, 2025

  Based on observations, record review and interviews, the facility failed to ensure resident rooms, resident equipment and shower rooms equipment were maintained in a clean and sanitary manner during three days (9/30/2025, 10/1/2025, and 10/2/2025) of three days observed. Findings included: During facility wide tours on 9/30/2025 at 10:45 a.m., 10/1/2025 at 8:20 a.m., 1:00 p.m. and on 10/2/2025 at 8:27 a.m., observations were made of resident wheelchair armrests cracked and torn, resident rooms soiled, toilet devices and shower chairs were not maintained in a sanitary manner and were observed with biogrowth. 1. During multiple tours of the main community shower room, observations revealed two plastic shower chairs that were wet and appeared to have been just used. […]

• No harm, potential for more than minimal, patternF925Oct 2, 2025

  Based on observations, staff interviews and record review, the facility failed to ensure an effective pest control program related to small flying insects in the kitchen, during two days (9/30/2025 and 10/1/2025) of three days observed. Findings included: On 9/30/2025 at 9:18 a.m. a kitchen tour was conducted with the Certified Dietary Manager (CDM). An observation was made of several small flying insects at the hand washing sink, approximately eight of these flying insects flying around and landing on the walls, the paper towel dispenser, the sink, and floor. The floor drain that had a metal plate was observed with gelatinous bio growth on it. The CDM revealed he had not seen them before until they were just pointed out. […]

• No harm, potential for more than minimal, patternF583Sep 20, 2023

  Based on observation, interview, and record review, the facility failed to maintain confidentiality of Protected Health Information (PHI) related to a bulletin board located in one of one nurses' station for a census of 52 residents related to having Do Not Resuscitate (DNR), mobility, tube feeding, and dialysis status being visible and accessible to visitors, residents, and staff members. The information was displayed at the nurse's station and the East Wing hallway bulletin board. Findings included: An observation on 09/19/23 at 9:00 a.m., behind the nurses' station located between the east and west wing, revealed a cart that contained all of the resident charts that showed the resident's name, room number and status of Do Not Resuscitate (DNR) for twenty-eight residents. […]