Health inspection·December 4, 2025

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (CMA) and the Case Manager (CM), the CMA stated Resident 1 was requesting to go to a different facility that allowed motorized wheelchairs. The CM stated initially Resident 1 was admitted for short term rehabilitation (a temporary, intensive therapy program helping residents recover strength, mobility, and independence after illness, injury, or surgery) but after he got admitted , the ALF told them that they could not take Resident 1 back. The CMA stated the social services department sent referrals to other skilled nursing facilities (SNF) to find a new place for Resident 1. The CMA stated she was made aware of the resident's intent to transfer to another SNF maybe a month after Resident 1 was admitted to the facility but did not remember when. The CMA stated she did not write any notes in Resident 1's medical record regarding Resident 1's request to transfer. The CMA stated Resident 1 switched to custodial care (long-term assistance with daily living activities like bathing, dressing, eating, and toileting) sometime in October of this year (2025). During an interview on 12/4/25, at 1:31PM, with the Business Office Assistant (BOA), the BOA stated she sent three referrals to three SNF's because those were the request of Resident 1. The BOA stated there was no response from anybody and she faxed the referrals on 11/22/25, and the social services department were responsible for following up on those referrals. During an interview on 12/4/25, at 2:31 PM, the Social Services Assistant (SSA) stated during a quarterly meeting on 11/3/25, Resident 1 verbalized that he wanted to transfer to a facility that can accept motorized wheelchairs. The SSA stated the front office (business office) sent the referrals. The SSA stated that social services follow up normally after a few days of sending the referral, by calling the facility and asking for the status of the referral sent. The SSA confirmed she had not followed up on the referrals sent for Resident 1. During an interview on 12/4/25, at 3:21 PM, with the Director of Nursing (DON), the DON stated when a resident gets admitted to the facility, usually they ask the hospital/facility what type of equipment the resident had. The DON stated Resident 1 came from the hospital, but his belongings arrived from the ALF where he previously lived. The DON stated that the facility was informed about Resident 1's motorized wheelchair when the ALF sent it to the facility. The DON stated that the social services department was the one responsible for following up on the referrals to these facilities. During an interview on 12/4/25, at 4 PM, with the Administrator (ADM), the ADM stated it was the responsibility of the social services department to find placement for the residents if they want to be transferred, send referrals, and follow up on those referrals. The ADM stated the business office assistant helps send the referrals and informs the social services department via email. The ADM stated the social services department would have to follow up on the referrals. A review of a facility's policy and procedure (P&P) titled, Discharge Summary and Plan, revised 12/16, the P&P indicated, .Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. A review of a facility's P&P titled, Assistive Devices and Equipment, revised 7/17 , the P&P indicated, .Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents.Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include, but are not limited to: a. Wheelchairs (manual only). A review of a facility's policy and procedure titled, Resident Rights, revised 12/16, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:.be informed of, and participate in, his or her care planning and treatment. A review of a facility's document titled, Job Description: Social Services Lead Assistant, indicated, .Duties and Responsibilities Administrative Functions.Participate in community planning (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 12/04/2025 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete related to the interests of the facility and the services and needs of the resident and family.Participate in discharge planning, development and implementation of social care plans and resident assessments.Assist in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required. A review of a facility's document titled, Job Description: Director of Social Service, indicated, .Duties and Responsibilities Administrative Functions.Participate in community planning related to the interests of the facility and the services and needs of the resident and family.Participate in discharge planning, development and implementation of social care plans and resident assessments.Assist in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required. Event ID: Facility ID: 555307 If continuation sheet Page 3 of 3