Clearwater Healthcare Center: Wrongful Discharge Case - CA
Clearwater Healthcare Center, on East Knickerbocker Drive in Stockton, removed the resident identified in inspection records as Resident 1 on the grounds that the facility could not meet their care needs. The specific need cited: deep suctioning, a procedure used to clear heavy mucus or blockages from the lower airway, in the event of a choking emergency.
The Director of Nursing confirmed to inspectors that Resident 1 had no documented episodes of choking during their stay. No progress notes flagged a need for deep suctioning. No incidents had been recorded. No concerns had been written down. The discharge was not a response to something that had gone wrong. It was a response to something that might, theoretically, go wrong someday.
The Director of Nursing said the facility lacked a respiratory therapist on-site to provide immediate intervention if such an emergency occurred. That was the basis for removing the resident.
Resident 1 appealed.
The appeal went to court. The resident won. By the time inspectors interviewed the facility's administrator on May 22, 2026, Clearwater had already been ordered to readmit Resident 1 within 72 hours.
The administrator confirmed all of this without apparent dispute.
What the inspection examined was not just whether the discharge was justified, but whether the facility followed its own documented procedures when it carried one out. Clearwater's transfer and discharge policy, last revised in December 2016, lays out specific requirements: when a resident is discharged because their needs cannot be met, the medical record must include documentation of what specific needs could not be met, what the facility attempted in order to meet them, and what services the receiving facility could offer that Clearwater could not.
Inspectors found the discharge documentation fell short of those requirements.
The policy also states plainly that a resident cannot be transferred or discharged while an appeal is pending. Whether that provision was honored before the court ruled is not detailed in the inspection record. What is clear is that the resident was out of the facility before the appeal concluded, and the court's ruling required their return.
A separate facility policy on discharge notices, revised in March 2025, requires that residents receive written notice of a transfer, including the specific reason, the effective date, and the location they are being sent to. A copy of that notice is also required to go to the Office of the State Long-Term Care Ombudsman.
The inspection, a complaint survey completed May 27, 2026, classified the violation as causing minimal harm or potential for actual harm, affecting a limited number of residents. That classification reflects the regulatory framework's language, not necessarily the experience of being discharged from a care facility over a risk your own medical record does not support.
Clearwater Healthcare Center is a licensed skilled nursing facility. Its address is 1517 East Knickerbocker Drive, Stockton, California.
Resident 1 was ordered home.
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 17, 2026 · Our methodology
CLEARWATER HEALTHCARE CENTER in STOCKTON, CA was cited for violations during a health inspection on May 27, 2026.
The specific need cited: deep suctioning, a procedure used to clear heavy mucus or blockages from the lower airway, in the event of a choking emergency.
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.