Clearwater Healthcare Center

Resident 1 because the facility was unable to meet Resident 1's care needs.

The DON explained that

blockages from the lower respiratory tract).

The DON stated the facility did not have a respiratory

could not be met was a risk, in case Resident 1 had an episode of choking.

The DON confirmed there was no documentation in Resident 1's progress notes that indicated Resident 1 required deep suctioning or had an episode of choking, and Resident 1 did not have any events related to a need for deep suctioning, nor any recorded concern about it.

The DON stated it was about the risk for Resident 1, but no actual events happened or were documented during Resident 1's stay at the facility.During an interview on 5/22/26, at 5:10 PM, the Administrator (ADM) stated Resident 1 appealed the discharge with the court and Resident 1 won the appeal.

The ADM stated the facility will need to readmit Resident 1 to the facility within 72 hours.Review of facility policy and procedure (P&P) titled, Transfer or Discharge Documentation, revised 12/16, indicated, Policy Statement: When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.

Policy Interpretation and Implementation: Each resident will be permitted to remain in the facility, and not be transferred or discharged unless . the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility . If a resident exercises his or her rights to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending .

When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: .

The basis for the transfer or discharge; . If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: the specific resident needs that cannot be met; . facility's attempt to meet those needs . receiving facility's service(s) that are available to meet those needs .

That an appropriate notice was provided to the resident and/or legal representative .

The date and time of the transfer or discharge .

The new location of the resident .

The mode of transportation . A summary of the resident's overall medical, physical, and mental condition .

The signature of the person recording the data in the medical record .Review of facility P&P titled, Transfer or Discharge Notices, revised 3/25, indicated, Policy Statement: Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.

Policy Interpretation and Implementation: .

Except as specified . the resident . are provided with written notice .

Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge .

The resident . are notified in writing .

The specific reason for the transfer or discharge, including the basis .

The effective date of the transfer or discharge .

The specific location ZXXX

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Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

who to contact for assistance.

The DSS further stated that failure to provide the notice could place

Ombudsman should have been notified and involved in the discharge process because the Ombudsman

the discharge decision, or needed assistance, the Ombudsman should be aware of the situation and involved to help protect the resident's rights and promote a safe discharge process.During an interview on 6/4/26 at 11:28 AM with the OMB, the OMB stated that the Notice of Discharge (NOD) is a legally required notice that must be provided to both the resident (or the resident's representative) and the Ombudsman when a facility initiates a discharge.

The OMB stated that because Resident 1 was a long-term care resident, it was expected that Resident 1 or his representative would receive a written Notice of Discharge at least 30 days prior to the discharge, unless an exception applied.

The OMB confirmed receipt of the facility's Notice of Transfer dated 4/7/26 but stated that the Ombudsman program did not receive a Notice of Discharge after the facility determined on 4/9/26 that Resident 1 would not be readmitted because the facility could not meet the resident's needs.

The OMB stated that the Notice of Discharge contains important information necessary to protect the resident's rights and ensure a safe and appropriate discharge process.

The OMB further stated that the notice provides the resident with sufficient time to understand the discharge decision, prepare for the transition, and exercise appeal rights if the resident disagrees with the discharge.

The OMB stated that a copy of the Notice of Discharge must also be provided to the Ombudsman because it was required by law and allowed the Ombudsman to advocate for the resident, review the appropriateness of the discharge, and ensure that the resident's rights were protected throughout the discharge process.

The OMB stated that failure to provide the Notice of Discharge to both the resident and the Ombudsman could place the resident at risk of not being fully informed of the discharge decision, available appeal rights, and discharge plan, and could hinder efforts to ensure that the resident is discharged to a safe and appropriate location with necessary services and supports in place.Review of facility policy and procedure titled, Transfer or Discharge Notices, revised 3/25, indicated, Policy Statement: Residents . are notified of . discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman .

Policy Interpretation and Implementation: .

The resident and representative are notified in writing of the following information . the specific reason for the transfer or discharge . the effective date of the transfer or discharge . the specific location . to which the resident is being transferred or discharged . An explanation of the resident's rights to appeal the transfer or discharge to the state, including the name, address, email, and telephone number of the entity which receives such appeal hearing requests . information about how to obtain an appeal form . how to get assistance in completing and submitting the appeal hearing request .

The name, address, and telephone number of the Office of the State Long-term Care Ombudsman . A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident.

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Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

During a review of Resident 1's clinical record titled, Order Summary Report, dated 5/22/26, the active orders as of 3/11/26, indicated, . TRACH STOMA (the opening in the neck where the tracheostomy tube goes): Cleanse around the stoma site & apply dry dressing .A review of Resident 1's clinical record titled, [Name of Facility] Progress Notes - History & Physical, dated 3/13/26, indicated, . He was hospitalized for inability to provide necessary tracheostomy care . PAST MEDICAL/PAST SURGICAL HISTORY .

Tracheostomy stoma . assessment and plan .

Status post tracheostomy: Continuing tracheostomy care .

During an interview with concurrent record review on 5/22/26 at 4:25 PM, Licensed Nurse (LN) 1 reviewed Resident 1's Care Plan Report and stated she was unable to locate a care plan addressing the resident's tracheostomy stoma care needs. LN 1 confirmed there were no identified care plan problems, goals, or interventions related to tracheostomy stoma management, respiratory monitoring, assessment for complications, or monitoring for signs and symptoms of infection. LN 1 stated that the care plan serves as the resident's plan of care and is an important communication tool to ensure all staff involved in the resident's care are aware of the resident's needs, goals, and required interventions.During an interview on 5/27/26 at 9:33 AM, the Assistant Director of Nursing (ADON) stated that it was her expectation that a care plan addressing Resident 1's tracheostomy stoma care needs should have been developed and implemented.

The ADON stated that a tracheostomy stoma is a significant clinical condition that requires individualized care-planned interventions to guide staff in the assessment, monitoring, and care of the stoma site.

The ADON further stated that an appropriate care plan was important to provide overall direction for care, promote consistent care delivery among staff, monitor for potential complications, identify signs and symptoms of infection, and minimize risks associated with the tracheostomy stoma.Review of facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 3/22, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Policy Interpretation and Implementation: The interdisciplinary team (IDT), in conjunction with the resident . develops and implements a comprehensive, person-centered care plan for each resident. care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions.

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Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

cognitive impairment (difficulty with memory and thinking), remained in the facility for approximately

reviewed with the ADON and indicated that Resident 5's BP was 144/68 at 8:52 AM and 76/40 at 4:37

according to the facility's 72-Hour Neuro-Checklist, five neuro check assessments with vital signs should have been completed between the fall at 2:50 PM and the BP reading of 76/40 at 4:37 PM and that hypotension and bradycardia on 12/17/25 were identified by non-nursing staff approximately two hours after the fall and that the lack of monitoring increased Resident 5's risk for another fall.Review of facility's policy and procedure (P&P), titled Falls and Fall Risk, Managing revised in 3/2018, the P&P indicated .Resident conditions that may contribute to the risk of falls include.cognitive impairment.orthostatic hypotension.staff will identify and implement relevant interventions.to try to minimize consequences of falling.Review of facility's policy and procedure (P&P), titled Falls - Clinical Protocol revised in 3/2018, the P&P indicated .In addition, the nurse shall assess and document/report the following.Vital signs.Neurological status.The staff and practitioner will review each resident's risk factors for falling and document in the medical record.cognitive impairment.hypotension.Based on the preceding assessment, the staff and physician will identify interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of falling,.such as hypotension.

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Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

wounds.Review of facility's policy and procedure (P&P), titled Infection Prevention and Control

prevent the development and transmission of communicable diseases and infections.Prevention of