Health inspection·June 2, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview by phone on 5/29/25 at 4:13 p.m., with the Long-Term Ombudsman Representative (OMB) 1, OMB 1 stated that he had not heard anything about Resident 2's impending discharge from the facility. During an interview on 5/30/25 at 10:05 a.m., with the facility Social Services Director (SSD), the SSD stated that residents received discharge notices from Social Services. The SSD stated that the notice might be given to the resident one day or one week ahead of time. The SSD stated that a discharge notice was given to a resident with a copy placed in their electronic medical record (EMR) and a copy was sent to the OMB afterwards. The SSD confirmed that Resident 2 did not receive a notice of discharge. The SSD stated that it was because the discharge was still pending, so she was not able to give a notice of transfer or discharge to Resident 2. During an interview on 5/30/25 at 11 a.m., Resident 2 stated that the facility staff came to her room one week before the discharge date and told her that she would be discharged on 5/1/25. Resident 2 stated that her FM (daughter) appealed the discharge. During an interview by phone with Resident 2's FM on 5/30/25 at 11:08 a.m., the FM stated that the facility notified her that Resident 2 was to be discharged one week before the discharge date of 5/1/25. The FM stated that she filed an appeal of the discharge. The FM confirmed that neither she nor Resident 2 received a formal discharge notice from the facility. The FM stated that the SSD told her that Resident 2 was to be discharged , and that she could appeal the discharge. The FM stated that she felt that the discharge was not safe. The FM stated that the facility staff told Resident 2 that she would be discharged [DATE]. The FM stated that she called the OMB's office on 4/30/25, and OMB 2 helped her file to appeal the discharge from the facility. The FM stated that OMB 2 came to the facility and spoke with the SSD and told the SSD that the FM filed an appeal, and that Resident 2 was not to be discharged from the facility pending the appeal. The FM stated that a licensed nurse (LN) came to Resident 2's room while OMB 2 was there and began to pack her things for discharge on [DATE], so she told the LN that the discharge appeal was pending. The FM stated that after OMB 2 left the facility, another LN came to Resident 2's room with her medications and discharge papers a short time later, and she refused to sign them and told the LN that the discharge appeal was pending. The FM stated that Resident 2 was anxious and thought that the facility was going to put her out on the street. The FM stated that she notified OMB 2, and OMB 2 made calls to the facility, and the discharge was put on hold. The FM stated that the appeal of the discharge was later granted. During an interview by phone with OMB 2 on 5/30/25 at 2:36 p.m., OMB 2 confirmed that the OMB's office did not receive a notice of discharge for Resident 2. OMB 2 stated that Resident 2 was anxious because the staff approached her about the discharge, but her FM was making the discharge arrangements, and the staff did not include the FM in the discharge conversations. OMB 2 stated that she came to the facility on 5/1/25 and talked with the SSD. OMB 2 stated that the SSD stated that Resident 2 could make her own decisions. OMB 2 stated that the SSD stated that Resident 2 had a safe place to be discharged to. OMB 2 stated to the SSD that Resident 2's FM stated that the place that the facility attempted to discharge Resident 2 to was not safe. OMB 2 stated that the SSD stated that the facility was not attempting to discharge Resident 2 since the discharge appeal was pending. OMB 2 stated that after she left the facility, she received a call from Resident 2's FM stating that the facility staff was attempting to discharge Resident 2. OMB 2 stated that she called the SSD, and the discharge attempt was stopped. A review of a facility policy and procedure (P&P) titled, Transfer or Discharge Documentation, revised 12/16, the P&P indicated, .Policy Statement .When a resident is transferred or discharged , (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555307 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 .2. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending . A review of a facility P&P titled, Transfer or Discharge, Preparing a Resident for, revised 12/16, the P&P indicated, .Residents will be prepared in advance for discharge .2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family . Review of an online article published by the California Advocates for Nursing Home Reform (CANHR) titled TRANSFER AND DISCHARGE RIGHTS, updated 9/4/24, the article indicated, .Written Notice Before transferring or discharging a resident, the facility must provide written notice to the resident and the resident's representative in a language and manner they understand . The facility must send a copy of the notice to the long-term care ombudsman program. Except when specified below, the notice must be given at least 30 days before the resident is transferred or discharged . Exceptions to 30-Day Notice .there are a few exceptions to the 30-day notice requirement. Federal regulations permit notice to be made as soon as practicable before transfer or discharge when: the health or safety of individuals in the facility would be endangered; the resident's urgent medical needs require a more immediate transfer; the resident's health has improved sufficiently to allow a more immediate transfer or discharge; or the resident has resided in the facility less than 30 days . Even if an exception to the 30-day notice requirement is satisfied, the facility must nevertheless provide written notice in advance of a proposed transfer or discharge and an opportunity to appeal. A nursing home cannot transfer or discharge a resident while an appeal is pending, unless delay would endanger the health or safety of the resident or other individuals in the facility . California law requires nursing homes to give reasonable advance notice in writing in all cases of transfer or discharge . (https://canhr.org/transfer-and-discharge-rights/) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555307 If continuation sheet Page 3 of 3