Other·May 8, 2019

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 #CA00608431. Representing the Department of Public Health: HFEN, 14362 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 05/03/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her 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: 0QUI11 Facility ID: CA030000773 If continuation sheet 1 of 3 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 05/01/2019 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 designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record, and policy review, the facility failed to follow their abuse reporting policy and procedure for one of one sampled Residents (Resident 1) when Resident 1 alleged abuse, and the facility failed to report the allegation of abuse within 24 hours to the State Survey Agency (California Department of Public Health) in accordance with State law through established procedures. This failure resulted in the allegation of abuse not being investigated by the State Survey Agency. Findings: On 4/5/19, at 11 a.m. review of Resident 1's clinical record revealed a "Progress Note" dated 1/18/18, and timed at 10:23 a.m. The note revealed, "SSD [Social Services Director] and ED [Executive Director] met with res [resident] to ask about reported accusations of mistreatment. Res [Resident 1] believes he has been attacked, had leg broken x [times] 2 since admit and that he dressed himself, walked out in all (Sic) and was attacked by a staff member." An additional "Progress Note" dated 1/18/18, and timed at 1:51 p.m. disclosed, "...that resident's perceived mistreatment has been addressed..." On 4/5/19 at 11:40 a.m., the facility Executive Director (Administrator) was interviewed. He stated he could not find any documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0QUI11 Facility ID: CA030000773 If continuation sheet 2 of 3 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 05/01/2019 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 evidence that the facility had reported the allegation of abuse to the California Department of Public Health. Review of facility policy titled, "Abuse Investigation and Reporting" with a revised date of July 2017 included the following: "...Reporting 1. "All alleged violations involving abuse, neglect, exploitation, or mistreatment...will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. the State licensing/certification agency responsible for surveying/licensing the facility..." and, "... 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0QUI11 Facility ID: CA030000773 If continuation sheet 3 of 3