Clearwater Healthcare Center: Discharge Failure Left Amputee Stranded - CA
He called his family member to come pick him up. When she arrived, he was crying. He told her nobody wanted him.
That is what inspectors found when they investigated Clearwater Healthcare Center following a complaint filed against the Stockton nursing facility. The inspection, completed April 29, 2026, documented how the facility transferred a resident, identified only as Resident 1, to a placement that was wholly unprepared for his needs, after giving the receiving facility information that was wrong.
Resident 1 had been admitted to Clearwater with a diagnosis of complete traumatic amputation between the knee and ankle of his right lower leg. He used a wheelchair. When Clearwater arranged his transfer to the independent living facility, staff told the facility's agency manager verbally that Resident 1 was "totally independent" and walked with a walker. No documentation was sent at all.
The agency manager said so himself. In a telephone interview with inspectors on April 30, he confirmed the facility sent him no paperwork for Resident 1. The staff at his facility, he explained, consisted of a cook, an owner, and a manager. They could not assist with showers, getting in or out of bed, or any physical care needs. An independent living facility, by design, is not equipped for that. Clearwater sent a wheelchair-dependent amputee there anyway.
The facility's own case manager assistant acknowledged the failure after the fact. In an interview with inspectors on April 29, she said that after Resident 1 had already been discharged, she spoke with the independent living facility's administrator and learned they couldn't accommodate a resident in a wheelchair. Her explanation was that it had been "a miscommunication," and that the facility "should have expressed that Resident 1 was in a wheelchair and would continue to require it."
That is one way to describe it.
The social services assistant told inspectors something more revealing. When asked what information the facility provided when transferring a resident to an independent living facility, she said the only document they sent was a face sheet, a single page containing demographic information, contact details, and a list of diagnoses. That was the standard practice. Not a care summary. Not mobility status. Not equipment needs. A face sheet.
Clearwater's own written policy on transfers, last revised in December 2016, states that when a resident is discharged, "all special instructions for ongoing care" and "all other necessary information to ensure a safe and effective transition of care" must be communicated to the receiving provider. The facility's social services assistant described a routine that did not come close to meeting that standard. The case manager assistant confirmed it failed here entirely.
Inspectors cited the violation at a level of minimal harm or potential for actual harm, one of the lower tiers in the federal classification system. The finding affected few residents. In the language of regulatory enforcement, this was not the most serious category of failure.
But the classification does not change what happened to Resident 1 on April 20. He arrived at a place that had been told he could walk. He could not. The three people who staffed that facility had no training and no authorization to help him with the most basic physical needs. He sat there until he could reach someone to come get him.
His family member told inspectors he was crying when she arrived. He said nobody wanted him.
He had just left a nursing home that had spent however many weeks or months preparing his discharge, and this is where that preparation led.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clearwater Healthcare Center from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CLEARWATER HEALTHCARE CENTER in STOCKTON, CA was cited for violations during a health inspection on April 29, 2026.
He called his family member to come pick him up.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.