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Deficiency Records for Clearwater Nursing and Rehabilitation Center
A list of the most recent deficiencies for Clearwater Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Clearwater Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-07-09 | 2024-08-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-09 | 2024-08-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-09 | 2024-08-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-09 | 2024-08-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-09 | 2024-08-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-09 | 2024-08-06 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-07-09 | 2024-07-25 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-07-09 | 2024-07-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-09 | 2024-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-09 | 2024-07-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-09 | 2024-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-09 | 2024-07-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-03 | 2024-07-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-03 | 2024-07-01 | 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 | 2024-06-03 | 2024-07-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-03 | 2024-07-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-03 | 2024-07-01 | N |
| Respond appropriately to all alleged violations. | Health | 2024-06-03 | 2024-07-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-06-03 | 2024-07-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-03 | 2024-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-03 | 2024-07-01 | 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 | 2024-06-03 | 2024-07-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-03 | 2024-07-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-03 | 2024-07-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-03 | 2024-07-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-03 | 2024-07-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-06-03 | 2024-07-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-03 | 2024-07-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-06-03 | 2024-07-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-06-03 | 2024-07-01 | 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 | 2024-06-03 | 2024-07-01 | 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 | 2024-06-03 | 2024-07-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-06-03 | 2024-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-03 | 2024-07-01 | N |
| Dispose of garbage and refuse properly. | Health | 2024-06-03 | 2024-07-01 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-03 | 2024-07-01 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-06-03 | 2024-07-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-06-03 | 2024-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-03 | 2024-07-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-21 | 2023-08-04 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-15 | 2023-01-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-11-08 | 2022-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-08 | 2022-12-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-11-08 | 2022-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-08 | 2022-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-08 | 2022-12-10 | 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 | 2022-11-08 | 2022-12-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-08 | 2022-12-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-08 | 2022-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-08 | 2022-12-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-08 | 2022-12-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-08 | 2022-12-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-08 | 2022-12-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-09 | 2022-09-08 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-08-09 | 2022-09-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-08-09 | 2022-09-08 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-05 | 2021-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-05 | 2021-05-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-05 | 2021-05-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-05 | 2021-05-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-05-05 | 2021-05-25 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-04-05 | 2021-05-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-05 | 2021-05-10 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-05 | 2021-05-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-05 | 2021-05-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-05 | 2021-05-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-05 | 2021-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-05 | 2021-05-10 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-04-05 | 2021-05-10 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-05 | 2021-05-10 | 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 | 2021-04-05 | 2021-05-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-05 | 2021-05-10 | 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 | 2021-04-05 | 2021-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-05 | 2021-05-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-05 | 2021-05-10 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-05 | 2021-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-05 | 2021-05-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-05 | 2021-05-10 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-04-05 | 2021-05-10 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-04-05 | 2021-05-03 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-04-05 | 2021-05-03 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-04-05 | 2021-05-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-05 | 2021-05-03 | N |
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