Health inspection·March 18, 2026

CLEARWATER HEALTHCARE CENTER California Code of Regulations, Title 22, § 72541. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 01/27/2026, at 10:27 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one complaint regarding resident care. The facility failed to report an unusual occurrence to the Department for Resident 1 when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility on 1/25/26. This deficient practice had the potential to delay the investigative process and compromise the safety of Resident 1. A review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility in January of 2026 with diagnosis of, but not limited to, sepsis (a life-threatening emergency caused by the body's extreme, dysfunctional immune response to infection, leading to tissue damage, organ failure, and potential death), acute osteomyelitis of the right ankle and foot (a serious, rapid-onset infection and inflammation of the bone, often caused by the bacteria staphylococcus aureus), and type 2 diabetes mellitus (a chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells cannot effectively use insulin). During a phone interview on 1/27/26, at 2:11 PM, with Licensed Nurse (LN) 4, LN 4 stated Resident 1 had asked for a lighter to smoke cigarettes during the early morning medication pass on 1/25/26. LN 4 further stated she told Resident 1 that she did not have access to a lighter at that time in the morning. LN 4 stated Resident 1 then proceeded to pack his belongings while she continued her medication pass. LN 4 further stated that around 5:15 AM, she went to Resident 1's room and he was longer there. LN 4 explained that she looked for Resident 1 throughout the building but was unable to locate Resident 1. LN 4 stated she then proceeded to report the missing whereabouts of Resident 1 to the Assistant Director of Nursing (ADON) and LN 5. During a phone interview on 1/27/26, at 2:25 PM, with LN 5, LN 5 stated that she contacted the ADON and the Director of Nursing (DON) to inform them of the situation that Resident 1 was not in the building. LN 5 stated she reviewed the facility camera footage and confirmed that Resident 1 left the outside gate of the facility at 4:57 AM on 1/25/26. LN 5 further stated that it was dangerous for Resident 1 to leave the facility because he had a peripherally inserted central catheter line (PICC- a thin, flexible tube inserted into an arm vein and advanced to a large vein near the heart for long-term [weeks/months] IV treatments like antibiotics, chemotherapy, or nutrition). During an interview on 1/28/26, at 11:50 AM, with the ADON, the ADON stated that part of the facility's elopement process for when a resident eloped was to contact the Department, the police department, the Ombudsman (an independent, neutral official who investigates, reports on, and helps settle complaints against organizations, acting as a confidential advocate for fairness), and other key personnel of the facility including the DON and the Administrator (ADM). The ADON further stated she contacted both the DON and the ADM around 7:20 AM on 1/25/26 that Resident 1 was not in the building. The ADON stated the facility was not located in a safe area of town, and it was cold and dark at the time Resident 1 left the facility. The ADON further stated Resident 1 had a PICC line and he had a history of drug use. The ADON explained that she was worried about the safety of Resident 1 and could not confirm if he was safe as the facility staff did not know where he was. During an interview on 1/27/26, at 2:55 PM, with the ADM, the ADM confirmed that he did not contact the Department, the Ombudsman, or Adult Protective Services (an agency that provides intervention services to protect elderly and dependent adults) after Resident 1 had left the building on 1/25/26. The ADM further stated that it would be difficult for the facility to determine if Resident 1 was safe. During a review of the facility's policy and procedure (P&P) titled, "Unusual Occurrence Reporting," revised 12/07, the P&P indicated, "...As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of our residents, employees, or visitors...Our facility will report the following events to appropriate agencies...Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors...Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations... A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations..." Therefore, the facility failed to report an unusual occurrence to the Department for Resident 1 when Resident 1 eloped from the facility on 1/25/26. This deficient practice had the potential to delay the investigative process and compromise the safety of Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.