Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure staff (CNA 5 and CNA 6) promoted
dignity for two of two sampled residents (Resident 49 and 84), by not standing over the residents as they
were assisted with dining during breakfast.
This deficient practice had the potential to affect Residents 49 and 84's self-esteem and self-worth.
Findings:
a. During a review of Resident 49's admission record, it indicated Resident 49 was originally admitted to the
facility on [DATE] and readmitted on [DATE], with diagnosis that included unspecified dementia without
behavioral disturbance (long term and often gradual decrease in the ability to think and remember, severe
enough to affect a person's daily functioning), bilateral osteoarthritis of the hip (the cartilage within a joint
begins to break down and the underlying bone begins to change), and spondylosis (age-related change of
the bones (vertebrae) and discs of the spine).
During a review of Resident 49's quarterly Minimum Data Set (MDS - a standardized assessment and
screening tool) dated 9/13/21, indicated Resident 49 had severely impaired cognitive skills for daily
decision-making. The MDS indicated the resident needed extensive assistance with bed mobility, transfers,
and dressing. The MDS also indicated Resident 49 was totally dependent with locomotion, toilet use,
personal hygiene, and bathing, and required limited assistance in eating (indicated staff provide guided
maneuvering of limbs or other non-weight-bearing assistance).
During an observation and interview on 11/2/21, at 8:47 a.m., in Resident 49's room, Resident 49 was
observed seated on a wheelchair. Certified Nursing Assistant 5 (CNA 5) was observed standing while
feeding breakfast to Resident 49. Resident 49 was observed extending her neck to look up to CNA 5. CNA
5 stated when assisting resident to eat, they are supposedly sitting down. CNA 5 was not able to answer
why she should sit down. She stated, I forgot the word for it. CNA 5 stated she was passing by and just
started helping the resident. CNA 5 later stated the reason staff sit down while feeding residents is for
dignity.
b. During a review of Resident 84's admission records, it indicated Resident 84 was originally admitted to
the facility on [DATE], and readmitted on [DATE], with diagnosis that included osteoporosis (disease that
weakens bones), epilepsy (a central nervous system (neurological) disorder in which brain activity becomes
abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness),
and generalized anxiety disorder (marked by excessive, exaggerated anxiety
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 15
Event ID:
555880
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0550
and worry about everyday life events for no obvious reason).
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 84's Quarterly Minimum Data Set (MDS - a standardized assessment and
screening tool) dated 10/24/21, indicated the resident had moderately impaired cognitive skills for daily
decision-making, and was totally dependent on staff for bed mobility, transfers, and dressing, locomotion,
toilet use, eating, personal hygiene, and bathing.
Residents Affected - Few
During an observation and interview on 11/2/21, at 8:52 a.m. in Resident 84's room, CNA 6 (employed for
27 years) was observed standing over Resident 84 while assisting the resident to eat. CNA 6 stated I can
sit down if I want, but it's easier to stand up. CNA 6 further stated she is not aware of any protocols to use
while assisting residents as they are eating.
During an interview with the Registered Nurse 2 (RN 2) on 11/4/21, at 3:35 p.m. RN 2 stated the facility
orients staff upon hire to sit down while assisting with feeding, the facility also does in-services periodically.
RN 2 stated staff sitting down while assisting residents to eat is mainly for dignity. RN 2 stated some staff
come inside the room not intending to stay but go to encourage residents to eat and help in cueing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 2 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to develop a plan of care for two of two sampled
residents (Residents 50 and 56):
a. Resident 50 had wandering and intrusive behavior, would enter other resident's rooms, make their beds
without permission and without washing her hands.
b. Resident 56 had a high risk for falls.
These deficient practices had the potential to result in a delay in care and services needed for Resident 50,
and falls for Resident 56.
Findings:
a. During a review of the admission record, Resident 50 was admitted to the facility on [DATE], with
diagnoses of Alzheimer's disease (general term for memory loss and other cognitive abilities serious
enough to interfere with daily life), major depressive disorder (mood disorder that causes a persistent
feeling of sadness and loss of interest and can interfere with daily life), and disorder of bone density and
structure (more likely to break).
During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool)
dated 9/13/21, indicated Resident 50 had moderately impaired cognitive skills for daily decision making and
required minimal assistance and minimal assist for bed mobility, transfer, dressing, toilet use, and bathing.
During an observation on 11/2/21, at 9 a.m., Resident 50 was observed in another resident's room making
the residents bed. Resident 50 stated it was okay for her to make the other resident's bed, because it was
her Hermana, my sister. Resident 50 stated she always made her bed.
During a concurrent observation and interview on 11/2/21, at 10:35 a.m. Resident 50 was observed putting
her own purse in Resident 51's closet. Resident 50 also complained of missing some clothes. CNA 7, (who
has been employed by the facility for one year) stated she has seen Resident 50 in other resident rooms
making other resident's bed. CNA 7 stated when staff see her, they tell her to stop and redirect her. CNA 7
stated Resident 50 always says it is her mother's bed she is making. Also, Resident 50 also thinks her
daughter works in the facility. CNA 7 then moved the purse Resident 50 placed in Resident 51's closet.
CNA 7 does not know why Resident 50's closet was empty.
During an interview with CNA 11 on 11/4/21, at 8:08 a.m., CNA 11 stated Resident 51 always takes her
clothes from the closet and packs them every morning, as if she is leaving the facility. The staff place
Resident 50's belongings in a box and put the clothes back when the resident needs them.
During an observation on 11/3/21, at 8:23 a.m. Resident 50 was observed making the bed for Resident 51
without washing her hands before and after touching Resident 51's linens and pillow. Resident 51 was
observed speaking Korean only to Resident 50, while tapping Resident 50's arm to get her to stop but
Resident 50 did not stop. Resident 51 sat quietly next to the bed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 3 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a record review on 11/4/21, at 9:50 a.m., there was no care plan developed to address Resident
50's behavior of wandering and intrusions to other resident's room.
During a concurrent interview and record review on 11/4/21, at 3:20 p.m. RN 2 stated, As long as Resident
50 is not harming herself or anyone staff just redirect the resident. RN 2 stated there is no care plan for
walking room to room, but there is a care plan for restlessness and anxiety. RN 2 stated Resident 50 goes
to other resident's room to say Hi and make conversations to other residents, that behavior does not need a
care plan. RN 2 stated it is important to have a care plan as part of Resident 50's care and to monitor her
behavior.
During a record review of the Baseline/Admission/Working Resident Centered Care Plans dated 11/4/21, a
care plan had been developed to address Resident 50's episodes of intrusiveness related to doing (fixing)
other resident's beds related to Dementia with behavioral disturbance.
During a review of the facility's undated policy and procedure titled, Assessments and Care Plans, it
indicated all residents admitted to the facility shall be fully assessed by the attending physician and all
disciplines within the facility to identify all problems and needs. This assessment will serve as a basis for the
resident plan of care and shall be updated and revised as deemed necessary by the interdisciplinary team
and required by OBRA.
b. During a review of Resident 56's admission and Discharge records indicated, the resident was originally
admitted to the skilled nursing facility on [DATE]. Resident 56's diagnoses included dementia (memory loss)
with behavioral disturbance and chronic obstructive pulmonary disease ([COPD] a long-term lung disease
that makes it hard to breath).
During a review of Resident 56's Fall Risk Assessment record dated 3/19/21, indicated the resident was a
high risk for falls. During a review of another Fall Risk Assessment record dated 6/28/21, indicated Resident
56 was at a high risk for falls.
During a review of Resident 56's Post Fall Assessment record dated 8/18/21, indicated the resident was
found on the floor face down. The resident had sustained a skin tear on the right forearm and a cut on the
bridge of the nose with discoloration.
During a review of Resident 56's Short-Term Care Plan dated 8/18/21, indicated Resident 56 was observed
on the floor with a skin tear on the right forearm and a cut on the bridge of the nose. The short-term care
plan goal was to minimize the resident's fall risk. The short-term care plan intervention included to instruct
the Certified Nurse Assistant to place Resident 56 in a reclining position when he's up in the wheelchair.
During a review of the clinical records for Resident 56, the Fall Care Plans dated 9/28/21, indicated
Resident 56 had the potential for a recurrent fall incident. The care plan goal indicated for Resident 56 to
not have any recurrent falls.
During a review of Resident 56's Minimum Data Set ([MDS] a standardized assessment and care plan
screening tool) dated 9/22/21, indicated the resident was rarely or never had the ability to understand
others and the ability to make self-understood. The MDS indicated, Resident 56 was totally dependent on a
two-person assistance with bed mobility and transfers. The MDS also indicated, Resident 56 had one fall
with an injury.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 4 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 11/3/21 at 1:42 p.m., Licensed Vocational Nurse (LVN 1) stated residents who were
at risk for falls, the facility created a long-term care plan with interventions to prevent falls.
During a concurrent interview and record review on 11/4/21 at 7:30 a.m., LVN 1 stated Resident 56 was
identified as a high risk for falls on 6/26/21. LVN 1 stated, she could not find a care plan for Resident 56
prior to the fall on 8/18/21. LVN 1 stated, the resident should have had a care plan developed prior to his fall
incident. LVN 1 stated, the care plan would have provided a plan to prevent a fall for this resident.
During a concurrent interview and record review on 11/4/21 at 7:51 a.m., the Director of Nurses (DON)
stated the facility develops a care plan for the residents according to their risk factors and the resident's
interventions are individualized. The DON reviewed the care plans for Resident 56 and was unable to find a
written care plan prior to the fall incident on 8/18/21. The DON stated, a care plan should have been
developed for Resident 56 prior to the fall incident.
During a review of the facility's policy titled Fall Prevention and Reduction Program undated, indicated the
foundation of a fall prevention program was the assessment. The policy also indicated, a comprehensive
long term care plan should be developed for residents identified to be at high risk for falls and should
identify and address risk, goals, and interventions or approach plan to prevent falls.
The facility's policy titled Assessments and Care Plans undated, indicated all residents admitted to the
facility should be fully assessed to identify all problems and needs. The policy indicated this assessment
would serve as the basis for the resident care plan.
The facility's policy titled Resident's Care Plan long & Short Term undated, indicated the objective was to
provide a systematic way of documenting the plan of care for each resident
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 5 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During
observation, interview, and record review the facility failed to ensure one out of two residents (Resident 5)
received proper assistance to locate his lost device and maintain his vision. The deficient practice resulted
in Resident 5 delay in receiving his as corrective glasses to maintain his visual abilities and had the
potential to decrease Resident 5 quality of life.
Residents Affected - Few
Findings:
During a review of the clinical records for Resident 5, the Admitting and Discharge Record indicated
Resident 5 was originally admitted on [DATE]. Diagnosis included dementia (memory loss), chronic kidney
disease (damage kidneys), and dependent on hemodialysis.
During a review of the clinical records for Resident 5, the optometry assessment dated [DATE], indicated
Resident 5 had recommendations and was prescribed new bifocal glasses for quality of life.
During a review of the clinical records for Resident 5, the Theft and Loss Monitoring Report dated 11/4/21,
indicated Resident 5 lost his eyeglasses around 10/27/21. The report indicated Resident 5 received a pair
of reading glasses and the faxed the order for Resident 5 bifocal glasses replacement.
During a review of the clinical records for Resident 5, the Physician Orders dated 8/1/20, indicated Resident
5 may have eye health vision consultation with follow up treatment if indicated
During a review of the clinical records for Resident 5, the Minimum Data Set ([MDS] a standardized
assessment and care screening tool) dated 8/3/2021, indicated Resident 5 had the ability to understand
others and to make self-understood. The MDS indicated Resident 5 required supervision with bed mobility,
transfer, dressing, eating, toilet use, and personal hygiene.
During a review of the clinical records for Resident 5, the Care Plan
During a review of the clinical records for resident 5, the Nurses Notes dated 10/18/21 and timed 10:53
p.m., indicated Resident 5 had glasses with corrective lenses. A note on 11/1/2021 and timed 4:28 p.m.,
indicated Resident 5 vision was impaired with ability to see large print but not regular print.
During an interview on 11/2/2021 at 9:33 a.m., Resident 5 stated his eyeglasses broken and got lost.
Resident 5 stated he was having difficulty seen and doing things without his glasses. Resident 5 stated he
notified the licensed vocational nurse (LVN 5) and she told him the facility was going to follow up on his
glasses.
During a concurrent interview and record review on 11/4/21, at 10:12 a.m., Social Services Director (SSD)
stated about two weeks ago, she was notified about Resident 5 eyeglasses being misplaced. SSD stated
she did not complete a theft and loss report and had not looked for the missing glasses for resident 5. SSD
stated she had not looked for Resident 5's eyeglasses because she thought Resident 5 glasses were
shades. SSD review the optometrist records dated 3/25/21 and stated Resident 5 received new bifocal
eyeglasses.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 6 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0685
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During an interview on 11/4/21, at 4:14 p.m., SSD stated the facility did not find Resident 5's eyeglasses
and she ordered a replacement. SSD stated the facility provided Resident 5 a pair of readers to ensure
Resident 5 could do his crossword puzzle until he waited for his new glasses.
The facility's policy titled Theft and Loss undated, indicated the social services designee would review and
evaluate the Theft and Log entries as well as address each incident at the time of occurrence. The policy
indicated the facility would take a photo of the resident's eyeglasses for easy identification, complete a theft
and lost report for lost or stolen properties. The policy indicated prompt communication about the theft and
loss would potentially quickly recover the missing item.
Event ID:
Facility ID:
555880
If continuation sheet
Page 7 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one of seven sampled residents (Resident 89) who
was at risk for falls was assisted by two staff after a shower as indicated in the resident's functional
assessment.
This deficient practice resulted in Resident 89 sustaining a fall and hitting her head on the floor.
Findings:
During a review of Resident 84's admission record indicated Resident 84 was initially admitted on [DATE]
and latest readmission date was on May 24,2018 with diagnoses not limited to, Osteoporosis (disease that
weakens bones), Epilepsy (a central nervous system (neurological) disorder in which brain activity
becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of
awareness), and Generalized Anxiety disorder (marked by excessive, exaggerated anxiety and worry about
everyday life events for no obvious reason).
During a review of Resident 84's Minimum Data Set (MDS - a standardized assessment and screening tool)
dated October 24, 2021, indicated the resident had severe impairment of cognitive skills for daily
decision-making. The MDS indicated the resident needed total dependence with bed mobility, two-persons
assist on transfers, and dressing. The MDS also indicated Resident 84 was totally dependent with
locomotion, toilet use, eating, personal hygiene, and bathing.
During a review of records of Resident 89's history of falls indicated an incident reported on October 31,
2021 at 10:15 a.m. was documented. The records indicated s/p (status/post - after) fall, slipped in
shower/tub lying left.
During a record review of the document titled Nurses Notes dated October 31, 2021 at 3:07 p.m. indicated
at the time of incident Resident 89 was in chair. The Nurses notes indicated the Certified Nurse Assistant
12 (CNA 12) was attempting to pull up resident's pants after giving her shower, when the CNA slipped, then
resident slid from shower chair on the floor, bumped back of head. The CNA immediately assisted resident,
and slight redness noted to lower back area but no first aid was required. The notes indicated no floor mat
was in place and the floor was slippery. CNA 12 was instructed to assure and use proper safety precautions
are always in place.
During a review of Resident 89's care plan for History of Falls dated August 03, 2020, indicated nursing
aide will assist with safe transfers with two-person assist, ambulation with one person assists and two as
needed, anticipate needs. On November 02, 2021, the care plan indicated Nursing fall update: October 31,
2021 instruct staff on proper positioning and proper transfer technique of resident, ask for assistance during
bathing/dressing and have proper safety precautions in place.
During an interview and record review with Registered Nurse (RN 2) on November 04, 2021 at 11:57 a.m.,
RN 2 stated Resident 89 needs two person assist with transferring but when showering, it is okay for one
person assist. RN 2 stated the documentation indicated only CNA 12 was assisting when transferring the
resident on the day of fall.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 8 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0689
Level of Harm - Minimal harm
or potential for actual harm
During an interview with CNA 12 on November 04, 2021 at 12:01 p.m., stated she was helping to pull up
Resident 89 on the wheelchair when she lost her balance, resident fell and hit her head. CNA 12 stated she
should have asked for help, but she thought she can pull the resident by herself. CNA 12 stated she
reported to Licensed Vocational Nurse 2 (LVN 2), who was the charge nurse (CN) that time. CNA 12 stated
the Resident was monitored throughout her shift and was endorsed to the next shift.
Residents Affected - Few
During an interview with CNA 6 on November 04, 2021 at 12:11 p.m., CNA 6 stated Resident 89 needs two
staff to transfer. CNA 6 stated she will not attempt to transfer Resident 89 without assistance. CNA 6 stated
Resident 89 can bear weight on her legs but was still heavy.
During an inter view with the DSD on November 04, 2021 at 12:11 p.m., DSD stated the facility conducts
in-services training and routine meetings for fall precautions. There is also a stand up meeting in the start of
every shift. The training starts upon employment, every six months, and incidental as well. The DSD stated
a total assist resident needs to two persons assist, if the staff cannot do it, ask for help. The DSD instructs
staff on transferring and moving techniques and ask the therapy department for assistance, when needed.
The DSD stated if the CNA was not following the plan of care (POC), the CNA gets written up for the safety
of residents and employees. The DSD stated when injury occurs, fractures, and hospital admission, will
have to report to health department. DSD stated all staff was responsible specially DSD because he has to
reeducate the staff again. DSD stated CNA 12 is a newly graduated CNA and the CNA just had her
orientation.
During an interview with LVN 2 on November 04, 2021 at 1:55 p.m., LVN 2 stated CNA 12 changed her
story a couple of times. LVN 2 stated she was called in the shower room and found Resident 89 down, side
lying. LVN 2 stated Resident 89 made eye contact after neuro assessment. LVN 2 stated neuro checks
should be done for 72 hours to monitor for change in level of consciousness. LVN 2 stated at the start of
every shift, staff are made aware of what are the specific needs of residents and expects them to know if a
resident needs two persons assist. LVN 2 stated she continuously reminded other staff to ask for
assistance. LVN 2 stated Resident 89's fall was avoidable because CNA 12 should have asked for
assistance. LVN 2 stated the CNA did not use the stuff (fall mat) and towels when the floor was wet.
During a review of the facility's Policy and Procedure titled Policy and Procedure on Fall Prevention
Program indicated on the Facility-wide Environmental Assessment an environmental assessment should be
done regularly as part of the Fall Prevention Program. Facility should identify common, recognizable
hazards that impact risk for falls. Staff must recognize and view the environment from the prospective of a
resident with multiple limitations. Environmental Interventions that can help prevent falls entails as much
environmental check and modification, such as bathrooms: Check floors frequently to ensure they are not
slippery, especially when wet. Tubs, showers, and floors should have non-skid mats. Care Planning comprehensive long term care plan should be developed for residents identified to be at high risk for falls or
further falls. Plan of care should:
Identify and address risk & confounding factors to fall incidents, such as: Impaired physical functioning
-resident would require assistance with mobility and locomotion.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 9 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility's Administrative staff failed to ensure the Certified
Nurse Assistant (CNA) staff was competent and had the necessary skills to safely care for one out of one
resident (Resident 5) who was receiving hemodialysis ([HD] is a process of purifying the blood of a person
whose kidneys are not working normally).
This deficient practice had the potential to result in severe bleeding and malfunction of the HD shunt (a
silicone tube surgically implanted into a vein and into an artery to move blood through a filter at a high rate)
site for Resident 5.
Findings:
During a review of Resident 5's admission and Discharge Record indicated, the resident was originally
admitted to the skilled nursing facility on [DATE]. The resident's diagnoses included dementia (a group of
thinking and social symptoms that interferes with daily functioning), chronic kidney disease (a longstanding
disease of the kidneys leading to renal failure) and was dependent on hemodialysis (a treatment to filter
wastes and water from your blood, as your kidneys did when they were healthy).
During a review of Resident 5's Physician Orders dated 8/1/20, indicated the resident went to hemodialysis
on Monday, Wednesday, and Friday. During a review of the physician's order indicated a nursing alert that
read, no blood pressures on the left arm.
During a review of Resident 5's Minimum Data Set ([MDS] a standardized assessment and care plan
screening tool) dated 8/3/2021, indicated Resident 5 had the ability to understand others and to make
self-understood. The MDS also indicated, Resident 5 required supervision with bed mobility, transfers,
dressing, eating, toilet use and personal hygiene. The MDS further indicated that Resident 5 required HD
treatment.
During a review of Resident 5's Care Plan dated 10/21/20, identified the resident's problem was the
presence of a left upper arm shunt related to hemodialysis. The care plan intervention for this problem
included to carefully handle the left upper arm during care and to observe for redness and bleeding.
During a review of a written dialysis note dated 11/1/21, indicated Resident 5 had a hemodialysis access,
on the upper left arm.
During a review of Resident's 5 Care Plan dated 11/4/21, indicated the facility had identified a problem for
end stage renal disease which required HD treatment, three times a week via (by) a shunt on the upper left
arm.
During a concurrent observation and interview on 11/3/2021 at 9:06 a.m., Certified Nurse Assistant (CNA
2) stated, she did not know where Resident 5's hemodialysis site was. CNA 2 also stated, she did not have
to take any special precautions to measure the resident's blood pressure (the force of circulating blood on
the walls of the arteries). CNA 2 stated, she measured the blood pressure for the resident on his left arm,
because it was closer to his heart. CNA 2 said, she did not know what a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 10 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
HD emergency kit was and had not seen one in the facility. The HD emergency kit was shown to CNA 2 and
she stated, the kit was used when residents scratched themselves.
During a concurrent interview and record review on 11/3/21 at 1:42 p.m., Licensed Vocational Nurse (LVN
1) stated, she notified the CNAs not to measure the blood pressure for Resident 5 on the left arm, where
the shunt is. LVN 1 stated, measuring the blood pressure on Resident 5's extremity could cause the
resident to lose a lot of blood, cause the blood pressure to drop and the resident could faint.
During a concurrent interview and record review on 11/4/21 at 7:51 a.m., the Director of Nurses (DON)
stated the CNAs should know not to take the blood pressure on the resident's left arm.
During an interview on 11/04/21 at 9:50 a.m., CNA 4 stated when she was assigned to work with the
resident and was told to measure his blood pressure, on the right arm. CNA 4 stated, she did not know the
reason why she was told to take the blood pressure for the resident, on the right arm. CNA 4 stated, she
assumed the reason was not to take the blood pressure on the left arm was to obtain an accurate
measurement.
During an interview on 11/4/21 at 3:18 p.m., the Director of Staff Development (DSD) stated he did not
provide hemodialysis in-service (training) for the staff. The DSD stated, he needed to include hemodialysis
in-service to the staff to ensure the CNAs knew how to safely care for a HD resident.
During a review of the facility's policy titled Care of the resident Receiving Renal Dialysis (undated),
indicated the shunt care where the shunt was located was important to prevent stress and tension which
could cause irritation to the canula-blood vessel connection as pressure above or below the extremity
should be avoided at all times. The policy also indicated, post dialysis care included the CNA would take
the resident's vital signs upon return from dialysis and would not take the blood pressure on the arm with
the shunt.
During a review of another facility's policy titled Care of the resident Receiving renal Dialysis undated
indicated, staff would be aware of special care and needs of the resident receiving renal dialyses. The
policy further indicated, the medical records would alert staff to location of shunt and blood pressure would
not be taken on arm with shunt.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 11 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview, and record review, the facility failed to follow the menu as written for 34 of
84 sampled residents on a regular diet. These residents received less rice and beans than what was written
on their menus.
This deficient practice had the potential to result in weight loss.
Findings:
During a review of the facility's undated Daily Menu Planner, the planner indicated the following items will
be served: Enchilada 1, beans ½ cup, rice ½ cup, fresh fruit ½ cup, green salad ½
cup, beverage 8oz, and coffee or tea.
During a concurrent observation and interview with a [NAME] (Cook 1) on 11/2/21, at 1:10PM, in the
kitchen, during tray line service for lunch, residents who were on regular diet, were served 1/3 cup of rice
instead of ½ cup as indicated on menu. [NAME] 1 also served 1/3 cup of beans instead of ½
cup beans as written on the daily menu. According to [NAME] 1, he didn't check the scoop sizes. [NAME] 1
also stated, he should have followed the menu. 34 out of 84 residents
During a concurrent observation and interview on 11/2/21, at 1:12pm, with Dietary Supervisor (DS), DS
stated, Residents got less rice and beans. DS also stated, Staff should always follow the menu and portion
sizes. DS added that he will provide in-services to the kitchen staff to ensure residents are provided propre
portion sizes, moving forward.
During a review of the facility's undated policy and procedure manual titled, Menu planning 4.9 Portion
control indicated, Portion control aids in maintaining satisfactory food cost, uniformity of product, ease in
food service, and helps assure that residents receive a nutritionally adequate diet. Foods are to be served
in the portion size designated on the menu. The policy also indicated the Dietary Supervisor was
responsible for training employees on the use of scoops, ladles, and scales, which facilitate portion control.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 12 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and interview, the facility failed to store, prepare and serve food in accordance with
professional standards for food service safety when:
Residents Affected - Some
1. One container of open tomato juice was stored in the reach in refrigerator with no open date. There was
also one container of thickened lemon water with an open date of 9/3/21, exceeding storage periods for
ready to eat food.
2. Nutritional supplements labeled store frozen with manufacturer's instructions to use within 14 days of
thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after
the indicated timeframes. One box of vanilla no sugar added shakes and one box of chocolate soy shakes
were stored in the walk-in refrigerator with no thaw date.
3. A tablespoon was stored inside a large plastic container of food thickener and the handle of the spoon
was inside the food thickener.
4. The facility did not use a food safe chemical sanitizer to clean food contact surfaces in the kitchen for
food preparation areas.
These deficient practices had the potential to result in foodborne illness in a medically vulnerable
population of a total of 84 residents.
Findings:
1.During a concurrent observation and interview in the kitchen on 11/2/21, at 9: 10a.m, Dietary Supervisor
(DS), stated, there was one container of open tomato juice in the reach in refrigerator next to the food
preparation area, with no open date. DS stated there was also one container of lemon-flavored thickened
water with an open date of 9/3/21. According to the DS, the dietary staff forgot to add the open date on the
tomato juice. DS stated, open items should be discarded within 24 hours per facility's policy, and that the
thickened water had exceeded its storage my two months. According to the DS it was important to indicate
open dates on items and discard expired items to prevent food borne illnesses.
2.During a concurrent observation and interview on 11/2/21, at 9:35a.m., DS there was one box of
individual cartons of vanilla flavored no sugar added shakes and one box of individual containers of
chocolate flavored soy shakes stored in the walk-in refrigerator with no thaw date. DS stated, when the
facility received the shipment the shakes were frozen. Ds also stated the shakes were stored in the
refrigerator to thaw. According to DS once the shakes thawed, they were good for 14 days and verified that
there were no thaw dates to monitor shakes if its expired.
During a review of the U.S. Food and Drug Administration Food Code, dated 2017, indicated, the
ready-to-eat, time/temperature control for safety, food should be marked by date or day of preparation, with
a procedure to discard the food on or before the last date or day by which the food must be consumed, sold
or discarded. The U.S. Food Code further stated, time/temperature control for safety refrigerated food must
be consumed, sold or discarded by the expiration date.
3.During a concurrent observation and interview on 11/2/21, at 9:15a.m., in the food preparation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 13 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
area, DS stated there was a spoon inside one large container of food thickener powder, with the spoon's
handle touching the thickener powder. DS also stated, the spoon should not be stored in the food.
During a review of the U.S. Food and Drug Administration (FDA) Food Code, dated 2017, the FDA Food
Code indicated, during pauses in food preparation or dispensing, food preparation and dispensing utensils
shall be stored, in food that is not time/temperature control for safety food with their handles above the top
of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. It
further indicated, the handles of utensils, even if manipulated with gloved hands, are particularly
susceptible to contamination.
4.During a concurrent observation and interview on 11/2/21, at 8:50 a.m., in the kitchen, Dietary Aide (DA
1) prepared a sanitizer using a container of germicidal cleaner found on the cart. The manufactures'
specifications on the container of germicidal cleaner did not indicate that the product was safe to use on
food preparation areas. DA1 stated he uses this solution to clean the counters and all of the food
preparation areas a as disinfectant.
During an interview on 11/2/21, at 8:52 a.m., DS stated, that the facility recently started using germicidal
cleaner found on the cart in the kitchen to disinfect counters used for food and meal service carts. DS
stated that the sanitizer solution company attached an automatic dispenser of the germicidal cleaner in the
chemical storage room for easy dispensing. DS added that was not aware if the product was food safe.
A review of Mix mate Germicidal Cleaner Technical data sheet, dated 2021, indicated, this product is not for
use on food contact surfaces.
During a review of the U.S. Food and Drug Administration Food Code, dated 2017, indicated, Code
7-204.11 Chemical sanitizers, including chemical sanitizing solutions generated on -site, and other
chemical antimicrobials applied to food-contact surfaces shall Meet the requirements specified in 40 CFR
180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations
(Food-Contact surface sanitizing solutions).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 14 of 15
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
555880
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clear View Convalescent Center
15823 So. Western Ave.
Gardena, CA 90247
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 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility's policy on Food brought in by family and
visitors, does not address how to store and reheat food to ensure safe and sanitary storage, handling, and
consumption.
Residents Affected - Few
This deficient practice had the potential to cause foodborne illness for a total of 84 residents that has food
brought in by family or visitors.
Findings:
During an observation on 11/3/21, at 10:25 a.m., there were staff lunch bags in the residents' nourishment
refrigerator, located in nursing Station 2. A label on the bottom drawer that indicted for resident food only.
There was no food inside the drawer for resident food only.
During an interview on 11/3/21, at 10:25AM, with Licensed Vocational Nurse 3 (LVN 3), the LVN stated With
Covid, food for resident was not stored because we do not know where the food is coming from LVN 3 also
stated, the refrigerator had a designated drawer for resident's food.
During an interview on 11/3/21, at 10:26a.m., Director of Nursing (DON), stated, the facility does not store
food for residents. If a family member brings food, the food must be eaten when the family member is here.
The rest of the food will be discarded. DON further stated, If we want to store food for residents', the
nourishment refrigerator has a dedicated space to store residents' food.
A review of the facility's policy titled Food Brought in by Responsible Parties, Resident Self Determination
and Participation Policy indicated the facility protected residents from foodborne illnesses. The policy also
indicated the facility would allow residents to eat foods brought in by their responsible parties and visitors, if
the food was brought in and eaten in the presence of the responsible party. According to this policy, Food
brought in by family members, friends and visitors would not be stored at the facility, served or reheated by
the facility's employees.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555880
If continuation sheet
Page 15 of 15
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Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
FAQ · About this visit
Common questions about this visit
What happened during the November 5, 2021 survey of CLEAR VIEW CONVALESCENT CENTER?
This was a inspection survey of CLEAR VIEW CONVALESCENT CENTER on November 5, 2021. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CLEAR VIEW CONVALESCENT CENTER on November 5, 2021?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.