Other·October 5, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00548020. Representing the Department of Public Health: HFEN, 29917 The investigation was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F203 SS=D NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE CFR(s): 483.15(c)(3)-(6)(8)

F203 10/03/2017 (c) (3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555307 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLEARWATER HEALTHCARE CENTER 1517 Knickerbocker Drive Stockton, CA 95210 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE paragraph (b)(5) of this section. (c) (4) Timing of the notice. (i) Except as specified in paragraphs (b)(4)(ii) and (b)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (b)(1)(ii)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (b)(1)(ii)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (b)(1)(ii)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (b)(1)(ii)(A) of this section; or (E) A resident has not resided in the facility for 30 days. (c) (5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555307 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLEARWATER HEALTHCARE CENTER 1517 Knickerbocker Drive Stockton, CA 95210 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. (c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. (c)(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555307 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLEARWATER HEALTHCARE CENTER 1517 Knickerbocker Drive Stockton, CA 95210 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on staff interview and document review, the facility failed to issue a Transfer/Discharge Notice to two of four sampled residents (Resident 1 and 3), prior to, or soon after the residents were discharged from the facility. This failure had the potential to cause residents to acquire transfer trauma, not knowing where they were going, nor the reason for the transfer and not being made aware of their transfer appeal rights. Findings: 1.) Review of the Face Sheet of Resident 1 indicated he had been a resident at the facility since mid 2016. According to the Physician Progress Notes dated 7/14/17, Resident 1's health condition worsened and the resident was transferred out of the facility to a general acute care hospital. Review of the resident's medical records failed to show that the facility had issued resident a Notice of Proposed Transfer/Discharge. When the facility's Director of Nurses (DON) was asked to re-check the files in search of the Transfer/Discharge Notice, she stated that records showed Resident 1 had requested a bed-hold, but confirmed there was no evidence a Transfer/Discharge Notice was ever issued. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555307 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLEARWATER HEALTHCARE CENTER 1517 Knickerbocker Drive Stockton, CA 95210 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2.) Review of the Face Sheet of Resident 3 indicated he had been a resident at the facility since late 2016. On 7/19/17, the physician wrote orders for Resident 3 to be sent to the hospital, instructing to, "Send Pt [patient] to ED [emergency department] ..." Review of the resident's medical record, failed to show that Resident 3 was issued a Notice of Proposed /Transfer Discharge. When the Medical Records Director and Administrator were asked if a Notice was ever issued, they both said no. The administrator added that, "there was not a need to issue a notice, since he was on a 7 day bed-hold. During an interview conducted with the Administrator on 8/30/17 at 11:10 a.m., she affirmed and indicated that, "Not everyone is given a notice when the facility transfers or discharges residents out of the facility." Review of the facility's policy titled, "NCD [Nursing Care Division] Transfer and Discharge," with release date of 9/21/2016, it indicated that when a notice is not issued just prior to a transfer or discharge that is initiated by the facility, "...notice is given as soon as practicable."

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 10/03/2017 (e)(1) Permitting residents to return to facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555307 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLEARWATER HEALTHCARE CENTER 1517 Knickerbocker Drive Stockton, CA 95210 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. (e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555307 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLEARWATER HEALTHCARE CENTER 1517 Knickerbocker Drive Stockton, CA 95210 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE document review, the facility failed to establish and/or follow written policies on permitting residents to return to the facility after hospitalization. When Resident 1 was ready to return to the facility following a brief hospital stay, though it was past the 7-day bed-hold period, the facility failed to promptly re-admit the resident to the first available bed. This failure had potential to cause Resident 1 undue stress/transfer trauma by preventing him from returning to his preferred/prior place of residence. Findings: Resident 1's clinical record indicated he had been a resident at the facility since mid-2016, and was sent to the hospital on 7/14/17, for evaluation and treatment. The resident's health condition required him to be admitted to the general acute care hospital (GACH) for treatment on 7/15/17 and he remained there until 7/25/17. Review of Resident 1's GACH records included: 1) Resident 1's admission record indicated he was admitted on 7/15/17 and discharged on 8/11/17. 2) Case Management Assessment/Discharge Planning Notes dated 7/24/17 indicated the hospital Social Worker called the facility to have the resident re-admitted on 7/25/17. A subsequent Case Management Note dated 7/25/17 indicated [name of the facility] will not take him back. 3) Discharge Summary dated 8/11/17 indicated Resident 1 had been stable for discharge for "quite some time." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555307 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLEARWATER HEALTHCARE CENTER 1517 Knickerbocker Drive Stockton, CA 95210 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE According to the facility's Room Assignment sheets, covering the period from 7/25 to 8/11/17, a total of 17 days, the facility had 7 to 12 available male beds on each of those days. In an interview with the facility's Administrator and Director of Nurses (DON) on 8/24/17 at 9:30 a.m., they were asked why Resident was not allowed to return to the facility. They both said that the facility did not need to accept him back because he had expired his 7-day bedhold. Review of the facility's policy titled, "NCD [Nursing Center Division] Bed Hold & Readmission," release date 9/20/16, indicated that, "Should a patient elect not to pay for the bed-hold beyond the allowed duration, then the patient will be readmitted to the first available bed..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CFXI11 Facility ID: CA030000773 If continuation sheet 8 of 8