Inspection visit

InspectionFebruary 23, 2024

CLEAR VIEW CONVALESCENT CENTERCMS #5558806 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 60's admission Record (Face Sheet), the Face Sheet indicated Resident 60 was initially admitted to the facility on [DATE]. Resident 60's diagnoses included dementia (the loss of thinking, remembering, and reasoning), anxiety (a mental state of being anxious, worried, and unable to relax), fibromyalgia (a condition that causes pain and tenderness throughout the body), and hypertension (a condition in which the force of the blood against the artery walls is too high). Residents Affected - Some During a review of Resident 60's History and Physical (H&P), dated 6/5/2023, the H&P indicated Resident 60 does not have the capacity to understand and make decision. During a review of Resident 60's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 2/13/2024, the MDS indicated Resident 60's cognition (ability to learn, reason, remember, understand, and make decisions) was not able to recall information when ask to repeat information. The MDS indicated Resident 60 needed partial assistance with activities of daily living (ADL) with dressing, putting on and taking off footwear, and toileting hygiene. During an observation on 2/20/2024 at 10:36 a.m. in Resident 60's room, the call light cord was hanging in the back of the bedside nightstand. The call light cord was not within reach for Resident 60 to use. During an observation on 2/21/2024 at 9:33 a.m. in Resident 60's room the call light cord was hanging in the back of the bedside nightstand. The call light cord was not within reach for Resident 60 to use. During a review of Resident 60's Care Plan-Falls, dated 8/21/2023, the Care Plan-Falls indicated, nurse aide was to 1. Encourage to ask for assistance 2. Call button in reach 3. Assist with ambulating, transferring, toileting. 4. Frequent visual checks 5. Anticipate needs as needed 6. Report pain indicators. During an interview on 2/22/2024 at 2:33 p.m. with Restorative Nurse Assistant (RNA) 1, RNA 1 stated the call light cords are attached to the sheets or even attached to the residents. RNA 1 stated our Residents at the facility had memory problems including Resident 60. RNA 1 stated Resident 60 the call light cord needs to be attached to Resident 60 or within reach. RNA 1 stated its important to have the call light cord within reach just in case Resident 60 needed something. RNA 1 stated if the call light cord is not within reach Resident 60 will not be able to get what she needs. During an interview on 2/23/2024 at 11:19 a.m. with Registered Nurse (RN) 1, RN 1 stated the process for the call light cords is to place the call light cord clip it on the pillow or sheets and if (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 11 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 02/23/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they needed assistance, we could get to Resident 60 right away. RN 1 stated the call light cord needed to be within reach and not behind the bedside nightstand. RN 1 stated Resident 60 had poor safety awareness and is at risk for falls. During an interview on 2/23/2024 at 11:36 a.m. with Director of Nursing (DON) 1, the DON 1 stated the call light cord is clipped to the beddings such as pillows. The DON 1 stated the call light cord can attached to the Residents clothing for the Residents that are confused. The DON 1 stated Resident 60 is confused, and the call light cord should be attached to her clothing. The DON 1 stated if the call light cord is not within reach Resident 60 could try to reach for the call light cord and could loss her balance and could fall. During a review of the facility's policy and procedure (P&P) titled, Answering Call Lights, date unknown, the P&P indicated, To give routine or emergency service to patients as need on request .Light cords should be within reach of the patient .Be sure to put the signal cord back where the patient can reach it easily. Based on observation, interview, and record review, the facility failed to ensure call lights or light strings were accessible for two of four sampled residents (Residents 60 and 81). This deficient practice had the potential for avoidable harm as the two residents would not be able to use their call light to request assistance if needed. Findings: a. During a review of Resident 81's Admitting and Discharge Record, the Admitting and Discharge Record indicated, Resident 81was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including atrial fibrillation (irregular heartbeat), dementia (loss of cognitive functioning, thinking, remembering, and reasoning), and macular degeneration (an eye disease that affects your vision). During a review of Resident 81's History and Physical (H&P), dated 3/9/2023, the H&P indicated, Resident 81 does not have the capacity to understand and make decision. During a review of Resident 81's Minimum Data Set ([MDS] resident assessment and care screening tool), dated 1/2/2024, the MDS indicated, Resident 81 needs supervision in eating, oral hygiene, and toileting hygiene. During an observation in Resident 81's room on 2/20/2024 at 12:12 p.m. Resident 81 was observed in bed with his call light wrapped around a fixture hanging on the wall and not accessible to Resident 81. During an interview on 2/20/2024 at 12:15 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated call light serves to alert staff to address resident needs. During a concurrent observation and interview on 2/20/2024 at 12:22 p.m. with Licensed Vocational Nurse 2 (LVN 2) in Resident 81's room, LVN 2 stated Resident 81's could not reach his call light because it was wrapped and hanging on the wall. LVN 2 stated all staff are responsible for checking if the resident had their call lights within reach. LVN 2 stated the purpose of the call light was to ensure residents can call for help if needed especially during emergency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 2 of 11 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 02/23/2024 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 0558 During a review of facility's policy and procedure (P&P) titled, Answering Call lights, undated, the P&P indicated, light cords should be within reach of the patient. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 3 of 11 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 02/23/2024 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice of Non-Coverage (ABN) forms to the Health Care Responsible Party for two of two sampled residents (Resident 22 and 26). Residents Affected - Few This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal and unknowingly paying for non-covered care expenses. Findings: During a review of Resident 22's Admitting and Discharge Record, the Admitting and Discharge Record indicated, Resident 22 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hyperlipidemia ((too many fats in your blood). The Admitting and Discharge Record indicated, Resident 22 had health care responsible party. During a review of Resident 22's History and Physical (H&P), dated 11/9/2023, the H&P indicated, Resident 22 does not have the capacity to understand and make decision. During a review of Resident 26's Admitting and Discharge Record, the Admitting and Discharge Record indicated, Resident 26 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Alzheimer's disease (a brain condition that causes a worsening decline in memory, thinking, learning and organizing skills), and hypertension (high blood pressure). The Admitting and Discharge Record indicated, Resident 26 had health care responsible party. During a review of Resident 26's History and Physical (H&P), dated 12/7/2023, the H&P indicated, Resident 26 does not have the capacity to understand and make decision. During an interview on 2/21/2024 at 1:15 p.m. with Minimum Data Set nurse 1 (MDS 1), MDS 1 stated the Social Service Director (SSD) was responsible in providing and explaining the NOMNC and ABN forms. MDS 1 stated the NOMNC and ABN forms should be issued to the health care responsible party as listed in the Admitting and Discharge Record form for residents who does not have the capacity to make healthcare decision. During a concurrent interview and record review on 2/21/2024 at 3:10 p.m. with SSD, the NOMNC and SNF ABN forms of Residents 22 and 26 were reviewed. SSD stated Resident 22's last covered day for Medicare Part A skilled services will end 1/5/2024 and Resident 26's last covered day for Medicare Part A skilled services will end 1/18/2024. SSD acknowledged that she had asked Residents 22 and 26 signed the NOMNC and ABN forms since the insurance coverage belongs to them. SSD confirmed and stated the NOMNC and ABN forms had not been sent to the healthcare responsible party for Resident 22 and 26. SSD acknowledged that Residents 22 and 26 were not cognitively intact. SSD stated by not informing the healthcare responsible party of Residents 22 and 26, their rights to appeal for their coverage were not honored. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 4 of 11 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 02/23/2024 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/21/2024 at 3:25 p.m. with the Director of Nursing 1 (DON 1), DON 1 stated the SSD should have called or mailed the NOMNC and ABN forms to the healthcare responsible party of Resident 22 and 26 since both residents have a diagnosis of dementia. During an interview on 2/21/2024 at 3:41 p.m. with the Administrator (ADM), ADM stated the facility has no policy and procedure for issuing NOMNC and ABN to the resident or responsible party. During a review of Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, the Form Instructions, indicated Center for Medicare and Medicaid Services (CMS) requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Providers are required to develop procedures to use when then beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee's representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 5 of 11 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 02/23/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate Level I Pre-admission screening and resident review (PASARR - a mental health assessment tool) was submitted to the state-designated authority in a timely manner for one out of five residents (Resident 76). This failure had the potential to result in Resident 76 not receiving appropriate mental health care. Findings: During a review of Resident 76's admission Record (Face Sheet), the Face Sheet indicated Resident 76 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 76's diagnoses included chronic kidney disease (damaged kidneys), schizoaffective disorder (mental health disorder marked with a combination of symptoms such as hallucinations, delusion, and depression), and atherosclerosis (thickening or hardening of the arteries). During a review of Resident 76's History and Physical (H&P), dated 2/5/2024, the H&P indicated Resident 76 does not have the capacity to understand and make decision. During a review of Resident 76's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 12/07/2023, the MDS indicated Resident 60's cognition (ability to learn, reason, remember, understand, and make decisions) was not able to recall information when ask to repeat information. The MDS indicated active diagnoses under psychiatric and mood disorder 1. Depression 2. Bipolar 3. Schizophrenia. During a review of Resident 76's admission Record (Face Sheet), dated 1/27/2023, the Face Sheet indicated Resident 76 was diagnosed with schizoaffective disorder, bipolar (a mental illness that causes dramatic shifts in a person's mood, energy, and ability to think clearly) type on 1/27/2023. During a review of Resident 76's PASARR Level I letter, dated 12/8/2021, the PASARR Level I indicated results were negative and no additional requirements necessary for the diagnosis of bipolar disorder. During a concurrent interview and record review on 2/22/2024 at 2:17 p.m. with Certified Nursing Assistant (CNA) 2, Resident 76's admission Record, dated 1/27/2023 was reviewed. The admission Record indicated, on 1/27/2023 there was a new diagnosis of schizoaffective disorder, bipolar type. CNA 2 stated the resident went to the hospital 12/2022 and the bipolar diagnosis was discontinued. CNA 2 returned to the facility 1/27/2023 and the diagnosis was changed from bipolar disorder to schizoaffective disorder. CNA 2 stated my role is to send out the PASARR letter after the MDS (Minimum Data Set) Coordinator notifies me to send the letter out. CNA 2 stated a new PASARR letter is sent out when there is a new psychotropic diagnosis. CNA 2 stated there should have been a new PASARR letter due to the diagnosis to schizoaffective disorder. CNA 2 stated by the PASARR not being sent this had the potential for Resident 76 to be lacking in health services needed for the resident. During a concurrent interview and record review on 2/22/2024 at 2:17 p.m. with MDS Coordinator, Resident 76's admission Record, dated 1/27/2023 was reviewed. The admission Record indicated, on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 6 of 11 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 02/23/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/27/2023 there was a new diagnosis of schizoaffective disorder, bipolar (a mental illness that causes dramatic shifts in a person's mood, energy, and ability to think clearly) type. The MDS Coordinator stated Resident 76 had a diagnosis changed from bipolar to schizoaffective disorder. The MDS Coordinator stated the last letter for the PASARR was sent out on 1/20/2021 and was not able to locate a new PASARR letter since the diagnosis change on 1/27/2023. The MDS Coordinator stated it was important to send the PASARR letter so we can categories the needs for Resident 76. The MDS Coordinator stated PASARR letter helps to give a clearer view on how to take care of the resident with a diagnosis of schizoaffective disorder. The MDS Coordinator stated since the new letter was not sent it placed the facility in a position of not knowing if Resident 76 can be taking care of at this facility or needed to be sent somewhere else. During a review of the facility's policy and procedure (P&P) titled, As part of the readmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder .The PASRR will be evaluated annually and upon any significant change for those individuals identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 7 of 11 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 02/23/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Check the blood pressure prior to administering Propranolol (blood pressure lowering medication) and Spironolactone (medication that removes extra fluid from the body). This deficient practice had the potential to result in a dangerously low blood pressure for one of five sampled residents (Resident 91). Findings: During a concurrent observation and interview on 2/22/24 at 8:26 AM with LVN1, LVN1 prepared Propranolol and Spironolactone for Resident 91. LVN1 was stopped from administering the medications to Resident 91 due to failure to check the blood pressure. LVN1 stated the blood pressure was not checked prior to giving the medications because the doctor didn't order parameters (a defined range) to hold the medication. If there are no parameters, nurses don't check the blood pressure. LVN1 stated if the blood pressure is already low prior to giving the medications, the medications will lower the blood pressure more. Low blood pressure can make the resident dizzy and they could fall. During an interview on 2/22/24 at 8:39 AM with LVN3, LVN3 stated prior to giving Propranolol and Spironolactone the blood pressure should be checked. The blood pressure should be checked because the medications will lower the blood pressure. If the blood pressure goes too low the resident could pass out or die. Nurses only check the blood pressure if there are parameters. During a review of Resident 91's admission Record (Face Sheet), the Face Sheet indicated Resident 91 was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember and make decisions), fracture of the right humerus (upper arm bone), hypertension (high blood pressure), osteoporosis (weak bones), and history of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 8 of 11 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 02/23/2024 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory test ordered by the physician was available in the resident's clinical records and results reported to the physician in a timely manner for one of one sampled resident (Resident 80). Residents Affected - Few This deficient practice had the potential for Resident 80 not receiving necessary medical treatment. Findings: During a review of Resident 80's Admitting and Discharge Record, the Admitting and Discharge Record indicated, Resident 80 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), hypertension (high blood pressure), and hyperlipidemia (too many fats in your blood). During a review of Resident 80's History and Physical (H&P), dated 6/1/2023, the H&P indicated, Resident 80 does not have the capacity to understand and make decision. During a review of Resident 80's Minimum Data Set ([MDS] resident assessment and care screening tool), dated 12/14/2023, the MDS indicated, Resident 80 needs supervision in toileting hygiene and personal hygiene. During a review of Resident 80's Physician Orders, dated 6/2/2023, the Physician Order's indicated to monitor Resident 80's lipid panel (a blood test that measures the amount of cholesterol [type of fat] in your blood), every six months of June and December. During a concurrent interview and record review on 2/22/2024 at 2:13 p.m. with Registered Nurse 1 (RN 1), Resident 80's Electronic Health Record (EHR) were reviewed. RN 1 stated there were no laboratory results of lipid panel that was drawn December of last year available in Resident 80's EHR. RN 1 stated there was no documentation indicating the facility communicates with the physician of Resident 80 that lipid panel results were reported and there was no documented evidence of follow-up with the diagnostic laboratory of what happened with the lipid panel result that should had been drawn December of last year. RN 1 stated it was important for Resident 80's to monitor her lipid panel since Resident 80 had been taking statin (drugs that can lower cholesterol) and Resident 80 is a high risk for heart attack and other cardiac complications. During an interview on 2/22/2024 at 3:34 p.m. with the Administrator (ADM), the ADM stated the facility does not have a policy and procedure for diagnostic laboratory and laboratory reporting to the physician. During an interview on 2/23/2024 at 10:50 a.m. with the Director of Nursing 1 (DON 1), DON 1 stated the facility does not have a process to track all residents laboratory results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 9 of 11 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 02/23/2024 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, interview, and record review the facility failed to ensure safe food storage and food date and labeling practices in the kitchen: Residents Affected - Some 1. The facility failed to date split peas after opening. 2. The facility failed to date individual cups of prune juices. This deficient practice had the potential to result in harmful bacteria growth that could lead to foodborne illness in 92 residents who will receive food and drinks from the kitchen. Findings: During an observation on 2/20/2024 at 9:00 a.m. in kitchen storage room, there was a clear container storing green split peas with no date of opening. During an observation on 2/20/2024 at 9:20 a.m. in the kitchen refrigerator had individual cups of prune juices with not date or labeled. During an interview on 2/21/2024 at 3:39 p.m. with Dietary Aide (DA) 1, DA 1 stated when a food item is opened and what is left over put the remaining item into a closed container. DA 1 stated the remaining food item should have an open date. DA 1 stated the food item was to be labeled with the name of the food product and put a date. DA 1 stated it is important to label and date the food so we can keep track of what needs to be thrown out. During an interview on 2/21/2024 at 3:39 p.m. with Dietary Aide (DA) 1, DA 1 stated the individual cups of prune juice should have been dated. DA 1 stated if the cups of prune juice do not have a date on them, we do not know if the prune juice is spoiled or not. DA 1 stated we would possible be giving the residents spoiled of prune juice and that could cause them to become sick. During an interview on 2/21/2024 at 3:44 p.m. with Dietary Supervisor (DS) 1, DS 1 stated once the food item is opened the remaining of the food is placed in a container. DS 1 stated the food should have a label and date. DS 1 stated the staff forgot to put the date on the split peas when the remaining split peas were put in the container. DS 1 stated not having the date on the food can altered the taste of the food after its prepared. DS 1 stated it is important to have the date to make sure the food is served fresh to the residents. During an interview on 2/21/2024 at 3:44 p.m. with Dietary Supervisor (DS) 1, DS 1 stated the cups of prune juice after it is poured into the cups it should have a date. DS 1 stated the cups of prune juice are good for two days and since there were no dates on the cups of prune juice we don't know when the prune juice was poured. DS 1 stated if the cups of prune juice were served to the residents; the residents had the potential to become sick. During a review of the facility's policy and procedure titled, Food Production and Storage, unknown date, All foods left over are to be placed in appropriate containers which are covered and labeled and dated .Dry storage open packages should be stored in lidded containers and properly labeled .Refrigerated storage all food items that are out of the original container will be properly covered, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 10 of 11 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 02/23/2024 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 labeled, and dated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555880 If continuation sheet Page 11 of 11

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Citations

6 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.

0558GeneralS&S Epotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0770GeneralS&S Dpotential for harm
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the February 23, 2024 survey of CLEAR VIEW CONVALESCENT CENTER?

This was a inspection survey of CLEAR VIEW CONVALESCENT CENTER on February 23, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CLEAR VIEW CONVALESCENT CENTER on February 23, 2024?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

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 June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·February 23, 2024