Clearwater Healthcare Center
CLEARWATER HEALTHCARE CENTER in STOCKTON, CA — inspection on April 29, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent interview and record
titled, PT Discharge Summary, discharge date [DATE] was reviewed.
The DOR confirmed the document indicated Resident 1 required supervision or touching assistance to ambulate with a front wheeled walker (FWW).
The DOR stated Resident 1 was not walking independently in the facility or with nursing staff only with therapy staff.
During an interview on 4/29/26 at 1:08 PM with the Social Services Assistant (SSA), the SSA stated when a resident transferred to an ILF the only information the facility provided to the accepting facility was the resident face sheet (document that included demographic information, contact information and diagnoses).
The SSA further stated she was under the impression that Resident 1 walked on his own with a front wheeled walker (FWW) and that the facility purchased Resident 1 a walker.
During a review of Resident 1's clinical document titled, OT [Occupational Therapy, treatment focused on enabling patients to perform daily activities and tasks] Discharge Summary, discharge date [DATE], the document indicated, .Assessment and Summary of Skilled Services.Patient Progress.Pt was able to complete functional mobility task modified independent, at wheelchair level (recommended).
Patient was able to hop up to 150 feet using FWW with SBA [stand by assist] .
During a telephone interview on 4/30/26 at 12:26 PM with the Occupational Therapist (OT), the OT stated the term modified independent meant that extra time or a device was required in order to complete a task.
The OT further stated the device Resident 1 required was a wheelchair.
The OT stated Resident 1 hopped on one leg if he had to, but a wheelchair was recommended as the safest discharge option for him until he received a prosthesis (artificial limb).
During an interview on 4/29/26 at 1:28 PM with the facility administrator (ADM), the ADM stated there had been a miscommunication between the facility and the ILF.
The ADM further stated that the facility believed the ILF was able to meet Resident 1' s needs.
The ADM stated the facility needed to overcommunicate with the facilities they discharged to in order to ensure residents' needs could be met.
During a review of a facility policy titled, Discharge Summary and Plan, revised December 2016, the policy indicated, .When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan.The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include.the degree of caregiver/support person availability, capacity and capability to perform required care.a copy of the following will be provided to the resident and the receiving facility.an evaluation of the resident's discharge needs.
555307 04/29/2026
Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210
During a telephone interview on 4/28/26 at 1:59 PM with Family Member (FM) 1, FM 1 stated Resident 1 was transferred to an Independent Living Facility (ILF) on 4/20/26. FM 1 further stated when Resident 1 arrived he was told by the ILF staff that they could not meet his needs since he was in a wheelchair. FM 1 stated the ILF was informed by the facility that Resident 1 was independent in his care needs and walked with a walker (mobility aid that provides support and stability while walking). FM 1 stated Resident 1 called her to pick him up at the ILF and when she arrived Resident 1 was crying and stated that nobody wanted him.
During a telephone interview on 4/30/26 at 9:36 AM with the ILF Agency Manager (AM), the AM stated the facility did not send him any documentation for Resident 1.
The AM further stated the facility assured him verbally that Resident 1 was totally independent.
The AM stated the ILF staff could not assist Resident 1 with any care needs such as showers, getting in or out of bed, or any type of physical care.
The AM stated the staff at the ILF consisted of a cook, the owner and the manager.
During an interview on 4/29/26 at 1:08 PM with the Social Services Assistant (SSA), the SSA stated when a resident transferred to an ILF the only information the facility provided to the accepting facility was the resident face sheet (document that included demographic information, contact information and medical diagnoses).
During an interview on 4/29/26 at 1:44 PM with the Case Manager Assistant (CMA) the CMA stated after Resident 1 had been discharged she spoke to the Administrator of the ILF, who told her they could not accommodate Resident 1 in a wheelchair.
The CMA stated that previously the ILF had been a board and care and had accepted residents in wheelchairs.
The CMA further stated it was a miscommunication between the ILF, and the facility and the facility should have expressed that Resident 1 was in a wheelchair and would continue to require it at the ILF.
During a review of a facility policy titled, Transfer or Discharge Documentation, revised December 2016, the policy indicated, .When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and the appropriate information will be communicated to the receiving health care facility or provider.Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider.all special instructions for ongoing care.All other necessary information. to ensure a safe and effective transition of care.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.