Health inspection·October 20, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and extrapyramidal (drug-induced movement disorders) movement disorder. During a review of Residents 27's Care Plan titled Self-Care Deficit dated 11/30/2021, indicated the care plan interventions included to keep the call button in reach. Residents Affected - Some During a review of Resident 27's H/P dated 12/15/2021 indicated Resident 27 did not have the capacity to understand and make decisions. During a review of Resident 27's MDS dated [DATE], indicated Resident 27 usually had the ability to understand and be understood by others. The MDS indicated Resident 27 required set up only for bed mobility, transfer, walk in room, walk in corridor, locomotion (moving from place to place), eating, toilet use, for dressing and personal hygiene. During an observation on 10/17/2027, at 11:00 a.m., Resident 27 did not have a call light and was requesting coffee. Resident 27 attempted to reach for his neighbors call light, lost his balance, and felt down on his bed. During a concurrent observation and interview with Certified Nurse Assistant (CNA 1), on 10/17/2022, at 11:15 a.m., CNA 1 stated Resident 27 did not have the call light within reach all morning because Resident 27 call light clip was broken. CNA 1 stated not having the call light within reach could put Resident 27 at risk for falls. During a review of Residents 46's admission record, indicated Resident 46 was admitted to the facility on [DATE], diagnosis included visual loss, epilepsy (is a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), unspecified osteoarthritis (wearing down of the protective tissue at the ends of bones) spastic hemiplegia (muscle on one side of the body being in a constant state of contraction) affecting right dominant side, and contracture (shorten and hardening of muscles) to the right upper arm. During a review of Resident 46's Physician Assessment H&P dated 2/8/2019, indicated Resident 46 was cooperative and alert. During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46's usually was able to understand and be understood by others. The MDS indicated Resident 46 requires two- person physical assist with bed mobility, transfer, toilet use, walk in corridor, and walk in room. During a review of Residents 46's Care Plan titled Baseline/Comprehensive Care Plans dated 2/9/2022, indicated the care plan interventions for Resident 46 included call light attached to Resident 46 to alert the nursing staff when resident 46 attempted to get out of bed or slide out of the bed on his own, and call button within reach. During an observation 10/17/22, 10:18AM, Resident 46 was seating on a chair next to his bed and his call light was not within reach. Resident 46 had a contracted left hand and appeared to have difficulty opening and closing both of his hands. During a concurrent observation and interview with Resident 46 and CNA7 on 10/19/22, at 9:14 AM, Resident 46 call light was clamped to Resident 46's left shoulder. The call light had a long string (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555881 If continuation sheet Page 2 of 7 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 555881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clear View Sanitarium 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some attached to the light switch. Resident 46 demonstrated how he used the call light by leaning forward and moving his left shoulder, but the call light was not triggered. The string attached to the call light was too long. CNA 7 stated Resident 46 used the call light by having the call light clamped was in the room next to Resident 46 and when asked how does Resident 46 call for assistance? CNA 7 explained that the clamped to Resident 46. CNA 7 asked Resident 46 to demonstrate how he use the call light for assistance. Resident 46 leaned forward and tried to move his left shoulder, but the call light did not call for assistance. During a review of the facility's undated policy and procedures (P/P) titled Nursing Policies and Procedures in Answering Call Lights the P/P, indicated a purpose to provide routine or emergency service to patients as needed on request. The policy further indicated the light cords should be within reach of the patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555881 If continuation sheet Page 3 of 7 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 555881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clear View Sanitarium 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 failed to ensure licensed and registered nurses assessed two of 21 sampled residents ((Resident 63 and 25) for the need of restraints prior to placing the residents on physical restraints. This deficient practice had the potential to place the residents at risk for unnecessary prolonged use of restraints. It also had the potential to lead to a decline in physical functioning, residents not being treated with respect and dignity, skin injuries and severe injuries such as strangulation or entrapment. Findings: a. During a review of Resident 63's admission Record (face sheet), the face sheet indicated Resident 63 was originally admitted to the facility on [DATE], with diagnoses including Vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage) with behavioral disturbance and major depressive disorder (a mental disorder characterized by loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thought). During a review of Resident 63's Minimum Data Set ([MDS] a standardized care assessment and assessment tool), dated 9/23/2022, the MDS indicated Resident 63 sometimes had the ability to understand others and usually was understood by others. The MDS indicated Resident 63 required one-person physical assist for bed mobility, transfer, walking in the room, and corridor, dressing, toilet use and personal hygiene. The MDS indicated Resident 63 required setup for eating. During a review of Resident 63's History and Physical (H/P), dated 10/3/2022, the H/P indicated Resident 63 did not have the capacity to understand and make decisions. During a review of Resident 63's Physician Orders dated 6/10/2022, Physician Orders indicated resident was to be restraint free, without wheelchair pelvic support one time per month starting on 6/19/2022 During an observation in Resident 63's room on 10/17/22 at 1:40 p.m. Resident 63 was sleeping in a wheelchair with pelvic support attached to the back of the resident's wheelchair. During an interview with Certified Nurse Assistant (CNA 5) on 10/19/2022 at 10:32 a.m. CNA 5 stated Resident 63 was always on restraints while in the wheelchair. CNA 5 stated Resident 63 was always sleepy and needed encouragement to wake up during meals. During an interview with the Director of Nursing (DON) on 10/19/2022 at 3:04 p.m. the DON stated Resident 63 was on restraints while in wheelchair. DON stated the facility performed restraint assessment for residents only one time per month. b. During a review of Resident 25's face sheet, the face sheet indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's diagnoses included unspecified psychosis (a severe mental disorder in which thought, and emotions were so impaired that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555881 If continuation sheet Page 4 of 7 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 555881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clear View Sanitarium 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 contact is lost with external reality) and major depressive disorder (a mental disorder characterized by a persistently loss of pleasure or interest in life, disturbed sleep, feelings of guilt or inadequacy, and suicidal thought). During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 sometimes had the ability to understand and be understood by others. The MDS indicated Resident 25 required one-person physical assist for bed mobility, transfer, walking in the room, corridor, dressing, eating, toilet use and personal hygiene. During a review of Resident 25's H/P, dated 10/3/2022, the H/P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 25's Care plans, there was no care plan for the use of a wheelchair self-release seatbelt. During a review of Resident 25's physician Orders dated 10/16/2022, Physician Orders indicated Resident 25 was to be restraint free, without a wheelchair self-release seatbelt one time per month starting on 6/12/2022 During an interview with Licensed Vocational Nurse (LVN 3) on 10/20/2022 at 11:30 a.m., LVN 3 stated Resident 25 had a self-release belt because the resident had fallen several times before and the seatbelt was supposed to prevent Resident 25 from having further falls. LVN 3 stated a restraint assessment was done once a month and discontinued based on each resident's needs. A review of the facility's undated policy and procedure (P/P) titled Restraints/Supports, the P/P indicated restraints/supports will be used only when warranted by a medical condition and ordered by the attending physician, and only when less restrictive measures had been tried and failed. The P/P indicated an ordering physician was required to obtain informed consent. The P/P indicated restraint procedures were used if medically appropriate and possible, used for a maximum of six days a week. The P/P also indicated the facility will practice approaches that will attempt to keep independent functioning to a maximum level. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555881 If continuation sheet Page 5 of 7 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 555881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clear View Sanitarium 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 Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to follow their policies and procedure on destroying controlled drugs (medications that can cause physical and mental dependence) for one out one medication storage room. Resident 17's Lorazepam (medication used to treat anxiety) 1 milligram ([mg] unit of measurement) was stored in a drawer easily accessed by all licensed staff, instead of a sperate, locked drawer, where all controlled drugs were stored when awaiting destruction. This deficient practice had the potential to result in residents receiving the discontinued medication and drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) Findings: During a concurrent observation and interview on 10/19/2022, at 1:20 p.m., with the Director of Nursing (DON) in the medication room, Resident 17's medication, Lorazepam 1 mg was observed in a locked drawer. The DON stated that the locked drawer was where the licensed nurses stored all discontinued narcotics (opioids derived medications to alleviate pain), and other controlled drugs. The DON stated when an order for a narcotic or controlled drug was discontinued, the licensed nurses were supposed to gather the receipt, wrap it around the cassette, and place the controlled medication in the locked drawer. The DON stated once the licensed nurses place the discontinued controlled medication in the second drawer, the licensed nurses were supposed to inform her (the DON), and she would place the controlled medication in a third drawer until the pharmacist picked them up for disposal. The DON also stated she was the only staff with access to the discontinued controlled medications. During an observation on 10/19/2022, at 1:25 p.m., in the medication room, Resident 17's Lorazepam 1 mg was observed with a discontinuation date of 10/5/2022. During an interview on 10/19/2022, at 1:30 p.m., with the DON, the DON stated she did not check the storage room second drawer daily. The DON stated was important for the licensed nurses to notify her when a narcotic or a controlled medication was discontinued so that she (the DON) could remove it from the second drawer and placed in on the third drawer where it was locked away until a pharmacist arrives to dispose of it. The DON stated the medication, Lorazepam 1 mg, should have been in the third drawer since it was discontinued on 10/5/2022. The DON stated the licensed nurse did not dispose of the controlled drug correctly and did not notify her the medication was discontinued. The DON stated the risk of a narcotic, or a controlled drug not being disposed correctly was the licensed nurses administering the discontinued medication to a resident. During a review of the facility's undated job description for licensed vocational nurse (LVN), the LVN job description indicated the responsibilities for an LVN was to maintain an accurate and safe control of all medication including narcotics. During a review of the facility's undated job description for DON, the DON job description indicated the principal duties of the DON was to maintain the medication and drug records as well as assure compliance with departmental policies and procedures. During a review of the facility's undated policy and procedure (P&P) titled Destroying Drugs the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555881 If continuation sheet Page 6 of 7 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 555881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clear View Sanitarium 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 P&P indicated, the DON should store the controlled drugs awaiting destruction under separate lock. A record of stored controlled dugs would be maintained. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555881 If continuation sheet Page 7 of 7