Clearwater Healthcare Center: Trach Care Plan Failure - CA
The man, identified in inspection records only as Resident 1, was admitted on March 11, 2026, with quadriplegia and tracheostomy status among his diagnoses. A doctor's order was in place from that first day: cleanse around the stoma site and apply a dry dressing. But the care plan, the document that tells every nurse and aide on every shift exactly what to do and what to watch for, never addressed the tracheostomy at all.
The facility's own history and physical notes, dated two days after admission, recorded that Resident 1 had previously been hospitalized because of an inability to provide necessary tracheostomy care. The facility knew. The gap was there from the start.
When inspectors reviewed the case on May 22, a licensed nurse pulled up Resident 1's care plan and searched it. She could not find a single entry addressing the tracheostomy stoma. No identified problems. No goals. No interventions for monitoring the site, assessing for complications, or watching for signs of infection. The nurse confirmed all of it herself, on the record.
She also explained what the absence meant in practice. The care plan, she told inspectors, is the communication tool that ensures every staff member involved in a resident's care knows what that resident needs. Without it, there is no shared roadmap. One nurse might handle the stoma one way. Another might handle it differently. A third might not know it requires attention at all.
The Assistant Director of Nursing said the same thing five days later, on the morning of May 27. She told inspectors she expected a care plan for the tracheostomy stoma should have been developed and implemented. She described a tracheostomy stoma as a significant clinical condition requiring individualized interventions to guide staff through assessment, monitoring, and care. She said a proper care plan was necessary to promote consistent care among staff, catch potential complications early, and minimize the risks that come with managing an opening in someone's neck.
The facility's own written policy required exactly that. Its care planning procedure, revised in March 2022, stated that a comprehensive, person-centered care plan with measurable objectives must be developed and implemented for each resident, covering physical, psychosocial, and functional needs. The interdisciplinary team, working with the resident, was supposed to build that plan from a thorough assessment and keep it current.
For Resident 1, none of that happened.
Inspectors classified the violation as carrying minimal harm or potential for actual harm, the lower end of the severity scale. But the gap they documented ran from the day of admission through the resident's transfer to the hospital, a span of more than two months during which a man who cannot move his arms or legs, who breathes through a hole in his throat, had no written plan guiding the people responsible for keeping that hole clean and uninfected.
A tracheostomy stoma can become infected. The tissue around it can break down. Secretions can accumulate. Granulation tissue can form and obstruct the airway. None of those possibilities were named in any care plan at Clearwater, because there was no care plan to name them in.
The inspection was triggered by a complaint and completed May 27, 2026. Clearwater Healthcare Center is located at 1517 East Knickerbocker Drive in Stockton.
Resident 1 was no longer in the building by the time inspectors arrived to ask about his care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clearwater Healthcare Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
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: August 18, 2026 · Our methodology
CLEARWATER HEALTHCARE CENTER in STOCKTON, CA was cited for violations during a health inspection on May 27, 2026.
The man, identified in inspection records only as Resident 1, was admitted on March 11, 2026, with quadriplegia and tracheostomy status among his diagnoses.
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.