Health inspection·July 18, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse for two of two sampled Residents (Residents 1 and 2). This deficient practice resulted in a delay for the State Agency to investigate the allegation of abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (group of conditions characterized by impairment in brain function affecting memory and judgment) with mild mood disturbances, major depressive disorder (mood disorder causing persistent feeling of sadness and loss of interest) and generalized anxiety disorder. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool) dated 5/18/2023, the MDS indicated Resident 1 had intact cognition (thought process) and required supervision for most of the Activities of Daily Living (ADLs) including bed mobility, transfer, walking, eating and toilet use. During a review of Resident 1's Nurses Notes dated 7/11/2023 at 12:53 a.m., the Notes indicated on 7/10/2023 at 7:25 p.m., Resident 1's roommate (Resident 2) punched Resident 1 on the back of his head and left cheek with a closed fist without reason. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes gradual decline in memory), dementia with psychotic disturbances (false beliefs that make it hard for someone to think clearly) and schizophrenia (severe brain disorder that can cause disorganized thinking). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and required supervision for most ADL's including bed mobility, transfer, walking and eating. During a review of Registered Nurse' (RNS 2) Statement dated 7/10/2023, the Statement indicated RNS 2 heard a resident (Resident 5) call for help and saw Resident 2 grabbing Resident 1's shoulder from behind with his fist raised ready to hit Resident 1. The statement also indicated Resident 5 (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 3 Event ID: 555881 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 07/18/2023 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)