Health inspection·September 4, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/20/25.A review of Resident 2's MAR, dated August 2025, indicated a 7 was documented for the 6 a.m. dose of Famotidine on 8/20/25. The chart code on the August 2025 MAR indicated that 7 indicated Sleeping.During an interview on 9/4/25, at 10:07 a.m., with LN 2, LN 2 stated that if a resident's medication was not available to administer during medication administration time, she would check to see if the medication was in the e-kit in the medication storage room. LN 2 stated that there was a list of medications and dosages available in the e-kit, so if the medication was in the e-kit, she would take the medication out of the e-kit and fill out the form indicating which medication she took and fax the form to the pharmacy so that the pharmacy could replace the e-kit. LN 2 stated that if the medication was not in the e-kit, she would call the resident's physician to let the physician know that the medication was not available in the medication cart or the e-kit. LN 2 stated that the physician sometimes gave a one-time order to give the medication when it arrived late, then the regular medication times resumed. LN 2 stated that she would document that the medication was not available and what steps she took to resolve it in the resident's progress notes. During a concurrent interview and record review on 9/4/25, at 12:10 p.m., with the Nurse Supervisor (SUP), Resident 2's electronic medical record (EMR) was reviewed. The SUP confirmed that on Resident 2's MAR on 8/20/25, at 9 a.m., a 13 was entered for the dose of Amlodipine and the dose of Linzess; where the LN would document that the medications were given. The SUP further confirmed the 13 was a code that indicated Drug not available. The SUP confirmed that on 8/20/25, at 6 a.m., a 7 was entered for the dose of Famotidine; where the LN would document that the medication was given. The SUP further confirmed the 7 was a code that indicated Sleeping. The SUP further confirmed that there was no progress notes documented in Resident 2's EMR on 8/20/25 that indicated why the medications were not given or that the physician or pharmacist was notified. The SUP stated that her expectation was that if a resident's medications were not available to give during the medication administration time, the LN called the pharmacy for follow up and notified the resident's physician. The SUP stated the LN needed to document in the resident's progress notes that the medication was not given and what was done about it. The SUP further stated that, if necessary, the LN needed to endorse a follow up to the oncoming shift LN. The SUP acknowledged that the facility policy was not followed. The SUP stated the risk was that Resident 2's medications were not given as ordered. The SUP further stated that Resident 2's blood pressure could elevate if Resident 2 did not receive the Amlodipine, Resident 2 could become constipated if Resident 2 did not receive Linzess, and Resident 2 could have indigestion if Resident 2 did not receive Famotidine. The SUP stated that the facility had a medication dispensing machine and was in the process of educating the staff on how to use the machine.During a phone interview on 9/4/25, at 1:29 p.m., with the Pharmacy Consultant (PHARM), the PHARM stated that there was a new medication dispensing machine at the facility and the medications needed for the residents were all in the machine. The PHARM further stated that if there was a medication that the staff needed that was not available in the machine, then the staff could get the medication from the e-kit. The PHARM stated that accessing the medications from the medication dispensing machine was the first priority at the facility, but if a LN did not have access to the medication dispensing machine the LN could get the medication from the e-kit. The PHARM further stated that using the medication dispensing machine was faster than using pharmacy delivery for medications. The PHARM stated that the LNs still needed to communicate with the physician and the pharmacy when medication doses were not available.A review of a facility policy and procedure (P&P) titled, Administering Medications, revised April 2019, indicated, .Policy Statement.Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.4. Medications are administered in accordance with prescriber (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 09/04/2025 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 0755 orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555307 If continuation sheet Page 3 of 3