Health inspection·November 18, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility failed to protect the rights of one of three sampled residents (Resident 2) to be free from physical abuse when, Resident 2, who was on continuous one-to-one (1:1 - a high-level intervention where a staff member provides continuous, direct observation of a single patient to prevent harm to themselves or others) observation, was punched in the chest by Resident 3, while Resident 2 wandered into Resident's 3's room unattended on 7/26/25.This failure had the potential to result in physical and psychosocial distress (state of emotional and psychological discomfort that can impact a person's well-being) to Resident 2.Findings:A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with a diagnosis of, .UNSPECIFIED DEMENTIA [a condition characterized by a gradual decline in memory, language, reasoning, and problem-solving, that interferes with daily life] .WITH OTHER BEHAVIORAL DISTURBANCE .A review of Resident 2's Minimum Data Set, (MDS - a resident assessment tool) dated 6/18/25, indicated Resident 2's cognitive skills (the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) for daily decision making was severely impaired (a significant decline in a person's mental capacity that affects their ability to function independently in daily life, typically requires substantial supervision or assistance).During a concurrent observation and interview on 9/10/25, at 1:23 PM, in Resident 2's room, with Certified Nursing Assistant (CNA) 1 and Resident 2, CNA 1 confirmed Resident 2 was on 1:1 observation. CNA 1 stated her job was to sit with Resident 2 because he was, confused and walks into everyone's room. CNA 1 further stated Resident 2 had a staff member always watching him. Resident 2 was observed awake, calm, and lying in bed. When Resident 2 was asked what happened, Resident 2 did not recall being punched in the chest on 7/26/25.During an interview on 9/10/25, at 1:34 PM, outside of Resident 2's room, (CNA) 2 stated the facility expectation when a resident was on a 1:1 was for safety reasons and to never leave the resident alone. CNA 2 further stated the procedure was to have another staff member relieve them if the staff had to take a break or do something else, CNA 2 explained that did not always happen. CNA 2 stated that when residents who were on 1:1 were left alone, something bad could happen, for example, the resident could fall, get hurt by another resident, or walk out of the facility.During an interview on 9/10/25, at 1:47 PM, Licensed Nurse (LN) 1 stated she was working on 7/26/25 when around 2:45 PM she heard a commotion coming from the hallway. LN 1 stated she came out of a nearby room and observed CNA 3 in the hallway with both Resident 2 and Resident 3. LN 1 stated CNA 3 reported she observed Resident 3 punch Resident 2 in the chest. LN 1 explained that Resident 2 was supposed to have a 1:1 staff member with him while he walked around the unit but confirmed when Resident 2 was punched, staff was not with him. LN 1 stated Resident 2 was on 1:1 observation to prevent something like this incident from happening. LN 1 further stated the abuse could have been prevented if the 1:1 staff member was with Resident 2.During an interview on 9/10/25 at 3:06 PM, CNA 3 stated on 7/26/25 around 2:40 PM she was walking in the hallway Page 1 of 3 555307 555307 11/18/2025 Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few near Resident 3's room and saw Resident 3 and Resident 2 in the doorway. CNA 3 further stated she could hear Resident 3 become agitated and yell at Resident 2, and then she observed Resident 3 lunge forward and punch Resident 2 in the chest. CNA 3 stated after the punch happened, she noticed Resident 3 lost his balance and CNA 3 went quickly toward him and caught him and assisted him to the ground. CNA 3 further stated that CNA 4 also witnessed the incident and came quickly to assist from another direction. CNA 3 stated CNA 4 re-directed Resident 2 to walk away, and he did. CNA 3 confirmed Resident 2 did not have a 1:1 staff member with him.During an interview on 9/10/25, at 4:41 PM, CNA 4 was able to recall the incident between Resident 2 and Resident 3 on 7/26/25. CNA 4 stated Resident 2 was walking around the unit when she heard Resident 3 say something loudly to Resident 2. CNA 4 stated she observed Resident 3 come to the doorway of his room, approach Resident 2, and punched Resident 2 in the chest. CNA 4 confirmed Resident 2 did not have a 1:1 staff member present with him at the time of the incident.During a concurrent interview and record review on 9/10/25, at 3:40 PM, the acting Social Services Director (SSD) reviewed Resident 2's electronic health record (EHR -a digital record of a patient's health information). The SSD reviewed Resident 2's progress notes (ongoing records documented by healthcare professionals that track a patient's illness, treatment and progress over time) and stated the records indicated Resident 2 was placed on 1:1 observation on 7/24/25 due to an incident that occurred on 7/23/25 when Resident 2 was found wandering the facility, hitting staff members, going into other resident's room, and tried to escape the facility.During an interview on 9/10/25, at 3:29 PM, the Charge Nurse (LN) 2 stated the procedure in the facility when a resident was on 1:1 observation was to have a staff member with the resident all of the time. LN 2 further stated each shift the charge nurse assigned a CNA to sit or walk with the resident for the entire shift. LN 2 explained Resident 2 was on 1:1 due to safety. LN 2 further stated if the staff member assigned to the resident on 1:1 observation takes a break or had to leave the resident's side for any reason; they were to have another staff member stay with the resident until the assigned staff member returns. LN 2 further explained it was important to watch them closely to prevent the residents from getting hurt or wandering out of the facility. LN 2 stated the risk to the resident if the 1:1 was not with them was the resident getting injured, wandering into other residents' rooms and getting them upset, or elopement (leaving the facility without staff knowledge or supervision). LN 2 further stated if a resident was on 1:1 observation it would be difficult for them to be physically abused since the CNA was with them and should re-direct or intervene.During an interview on 9/11/25, at 8:42 AM, the Administrator (ADM) stated the expectation for Resident 2 and any resident on 1:1 observation was to have a staff member with the resident twenty-four hours a day. The ADM further stated Resident 2 was a risk for wandering which was why he was placed on continuous 1:1 observation.A review of Resident 2's care plan revised 7/24/25, indicated, .Resident [2] is at risk for fall related to: Unspecified Dementia.1:1 CNA to closely monitor behavior for patients safety.A review of Resident 2's care plan revised 7/11/25, indicated, .Resident [2] is an elopement risk/wanderer AEB [as evidenced by] disoriented to place, history of attempts to leave the facility unattended.resident wanders aimlessly.1:1 with CNA AM and PM shift for close monitoring and to ensure safety.A review of Resident 2's progress note dated 7/23/25, indicated, . [Resident 2] is hitting staffs [sic] and going into other patients room.A review of Resident 2's progress note dated 7/24/25, indicated, .spoke with [Resident 2] about not entering rooms. 1:1 in place for safety.A review of Resident 3's care plan initiated 7/26/25, indicated, .Altercation.[Resident 3] struck [Resident 2].A review of Resident 3's care plan revised 1/27/25, indicated, .[Resident 3] struck [another resident] on the back with a pillow.Goal.Will have no further incidents.A review of a facility policy titled, Abuse Prevention Program, 555307 Page 2 of 3 555307 11/18/2025 Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revised 12/16, the policy indicated, .Our residents have the right to be free from abuse.This includes but is not limited to.verbal, mental, sexual or physical abuse.As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone in the building.other residents.A review of a facility policy titled, Abuse and Neglect - Clinical Protocol, revised 3/18, the policy indicated, .The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse.A review of a facility policy titled, Wandering and Elopement, revised 3/19, the policy indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm.If identified as at risk for wandering.the resident's care plan will include strategies and interventions to maintain the resident's safety. 555307 Page 3 of 3