Advanced Care Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

he also identifies concerns when he make his rounds in the facility. The NHA said nursing aides are o trained to report concerns in the work order system. The NHA said he would expect his staff to report any room lights that are out , electrical cords hanging from light fixtures, holes in the walls, any bed cords plugged in inappropriately, and other environmental concerns in the facility. He said when the staff bring concerns about beds with brown colored oxidization, he orders new ones. The NHA said staff should have brought the concerns to his attention.Review of the facility policy titled, Homelike Environment Revision date 02/2021, revealed policy statement: Resident are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belonging to the extent possible.Policy Interpretation and implementation: 2. The facility staff and management, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment (Photographic Evidence Obtained)

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Care Center

401 Fairwood Ave Clearwater, FL 33759

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#3 today (with the DON and ADON). She stated it looked like an old bruise to her. She stated it was dark, red, black, purple bruised area about the size of a golf ball. She stated she did not measure it. She stated

she was not aware of the bruise until the DON came down today to look at it.Review of the facility's policy, Change in a Resident's Condition or Status, revised February 2021, showed: - Our facility promptly notifies

the resident, his or her attending physician, and the resident representative of changes in the residence medical /mental condition and / or status.Policy Interpretation and Implementation:1. The nurse will notify

the resident's attending physician or physician on call when there has been an accident or incident involving the resident b. Discovery of injuries of an unknown source.2. A significant change of condition or a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan;3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2011 showed Residents have

the right to be free from abuse, neglect, misappropriation of resident property and exportation. 8. Identify and investigate all possible incidents of abuse, and neglect, mistreat or misappropriation of resident property. 9e. Investigate and report any allegations within time frames required by federal regulations. 10.

Protect residents from any further harm during investigations.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Care Center

401 Fairwood Ave Clearwater, FL 33759

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurses to call the provider before putting orders into the computer for a resident. The DON said as far as blood glucose checks she said there were batch orders that everyone can have a blood glucose check for signs or symptoms of high or low blood sugar. She said if a resident says they are diabetic the nurse should do blood glucose checks. The DON said for Resident #1 the fact he wasn't getting insulin was brought to

the facility's attention when the resident filed a grievance. She said she would have expected the nurse to call the doctor if a resident told them they should have insulin and were not getting it. The DON said regarding Resident #2, just because she is diabetic doesn't mean she would get insulin or need blood glucose checks. She said it was concerning that nurses were not calling the provider to reconcile medications on admission. The DON said the facility did have an admission checklist, but it depended on

the nurse if they used it or not.A follow-up interview was conducted with the DON on 10/15/25 at 6:45 p.m.

The DON said the day after a resident's admission the resident is reviewed in the morning clinical meeting.

She said they ensure everything is in the record and match what came from the hospital. The DON said she was not there when Resident #1 and #2's records would have been reviewed, and the clinical team didn't remember if they reviewed them.An interview was conducted on 10/15/25 at 6:48 p.m. with the Assistant Director of Nursing (ADON). She said when reviewing new admission in the clinical meetings the Unit Manager (UM) reviewed the admission paperwork and the resident's electronic medical record if pulled up

on the big screen. She said the UM goes through the paperwork from the hospital and they all make sure

the orders were entered correctly. She did not recall if Resident #1 and #2's records were reviewed.An

interview was conducted on 10/15/25 at 6:55 p.m. with Staff F, LPN/UM. Staff F said she did admission

record reviews and in that process, she made sure batch orders were in place, she checked medications on

the discharge paperwork and ensured correct doses were ordered. Staff F said she did not recall Resident #1 or #2's review. She said seeing stop insulin on the hospital discharge paperwork wouldn't necessarily make her question it because some residents are on insulin temporarily in the hospital, but if a resident and/or RR said the resident was on insulin she would call the doctor or expect the nurse to call and get orders for insulin and/or blood glucose checks.Residents #1 and #2 primary care provider could not be reached.Review of the facility admission Checklist included but not limited to: -Add/Verify Attending Physician-Input Diagnosis and review H&P (history and physical)-Review hospital discharge orders-Add/Verify MD (medical doctor) orders from discharge med reconciliation ensure appropriate diagnosis, route, parameters. Ensure each diagnosis is covered in medication regimen if applicable.On 10/15/25 at 7:04 p.m. the DON stated the facility did not have a policy on medication reconciliation or diabetes management or the admission process.Review of a facility policy titled Physician Services, revised February 2021, showed: Policy Statement - The medical care of each resident is supervised by a licensed physician.Policy Interpretation and Implementation showed:1. A physician must recommend in writing that

an individual be admitted to the facility. This can be accomplished through:a. hospital transfer summary completed by a physician;b. admission paperwork completed by the resident's physician in the community:c. other written form completed by a physician; ord. a physician 's admission orders for the resident's immediate care.2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Care Center

401 Fairwood Ave Clearwater, FL 33759

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews the facility failed to ensure referral for urology consultation/evaluation was provided for one resident (#5) of three residents sampled.Findings Included: Review of an admission

Record dated 10/23/2025 revealed Resident #5 was admitted to the facility on [DATE REDACTED] with diagnoses to include but not limited to Type 2 Diabetes Mellitus with hyperglycemia, neuromuscular dysfunction of bladder, unspecified, infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter, chronic kidney disease, stage 3A. Review of an order summary dated 10/23/2025 showed:Consult Urology for urinary retention, verbal active order, dated 10/23/2025. Review of a progress note dated 10/08/2025 created by Staff G, Advanced Registered Nurse Practitioner (ARNP) noted to start a voiding trial on Resident #5. If voiding trial fails reinsert indwelling foley and consult urology. Review of a progress note dated 10/13/2025 created by Staff G, ARNP showed Staff G gave verbal orders previously

on Friday for voiding trial, but it was not done for unknow reasons. Staff G noted she spoke with nursing and

the Director of Nurses (DON) about the plan and requested voiding trial to be done and if voiding trial fails, consult urology. Review of a progress note dated 10/20/2205 created by Staff G, ARNP showed on 10/20/2025, Resident #5 did not pass voiding trial despite electronic record documentation indicating otherwise. Staff G noted Resident #5 had not voided with need for straight cath (catheterization) and greater than 400 mls [milliliters] output with urinalysis with culture and sensitivity obtained and + yeast, see labs and plan. On 10/23/2025 at 2:00 p.m. an interview was conducted with the Director of Nurses, DON.

The DON said the ARNP put Resident #5 on a voiding trial because she did not have justification for the use of a foley catheter. The DON stated the ARNP wanted Resident #5 to start a voiding trial. The DON said, When we conducted the trial, the resident failed. The DON said the Nurse Practitioner noted to consult urology if Resident #5 failed the trial, but she did not put an order in the system. The DON said when she reached out to the ARNP she told them to just leave the foley in. The DON said the ARNP could have put

the urology consult order in the system if she wanted Resident #5 to be seen by urology. On 10/23/2025 at 3:30 p.m. an interview was conducted with Staff G, ARNP. The ARNP said she wrote in her progress notes to start a voiding trial on Resident #5 because she had a diagnosis on her 3008 for acute retention. She said she told the nurse and the director of nurses twice if the resident failed the voiding trial to consult urology. She said the director of nurses reached out to tell her the resident was not voiding, and they only obtained 2000 milliliters of urine. The ARNP said she told the DON they needed to get a consultation from urology. The ARNP said once she gave the facility a verbal order they should have put the urology consult order in the system. She said she told the Unit Manager and the DON both to consult urology if the resident did not pass the voiding trial. She said the told the Unit Manager on Friday and told the DON again on Monday to consult urology for Resident #5. She said she told them to leave the foley in and consult urology

The facility did not have a policy/procedure regarding care consultation and referral.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Care Center

401 Fairwood Ave Clearwater, FL 33759

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor and/or Unit Manger.Drug Administration Functions Review medication cards for completeness of information,) accuracy in the transcription of the physician's order, and adherence to stop order policies. Notify the attending physician of automatic/stop/orders prior' to the last dosage being administered.Nursing Care Functions Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary. Maintain established nursing objectives and standards.

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Facility ID:

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