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 Page 1 of 3 555881 555881 07/18/2023 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few claimed Resident 2 had already struck Resident 1 from behind 3 times and that Resident 1 stated he was struck once by Resident 2. During a review of the facility's email correspondence dated 7/11/2023 at 5:27 p.m., the email indicated an SOC 341 (a form to report suspected dependent adult/elder abuse) was sent to the State Agency reporting Resident 2 grabbed Resident 1's shoulder and possibly struck Resident 1. During interviews on 7/18/23 at 9:23 a.m. and 9:50 a.m. with Resident 1, Resident 1 stated on (7/10/2023), he was speaking to his neighbor (Resident 5) when Resident 2 came up behind him and hit him on the left side of his face. Resident 1 stated he did not feel safe. Resident 1 stated Resident 2 also tried to hit a nurse when he did not want to take a shower two days prior to the incident on 7/10/23. During an interview on 7/18/23 at 1:24 p.m. with the Administrator (ADMN), the ADMN stated abuse was any kind of harm presented towards someone which could include neglect, exploitation, sexual, and emotional harm. The ADMN stated he had reported the incident because Resident 1 said he was hit, and it was confirmed that two staff members had to remove Resident 2 away from Resident 1. The ADMN stated it was important for incidents to be reported to the State Agency so that a thorough investigation could be conducted and to keep residents safe. The ADMN also stated any incident resulting in serious harm should be reported to the State Agency within 2 hours and could still report the incident within 24 hours. During an interview on 7/19/23 at 1:42 p.m. with the Director of Nurse (DON), DON stated the facility did not have report the allegation of abuse to State Agency within 2 hours because Resident 1 had no injuries or evidence of abuse. During a review of the facility's undated Policy and Procedure (P&P) titled, Policy and Procedure for Reporting Suspected Crimes Under the Federal Elder Justice Act , the P&P indicated the following: 1. When staff suspect a crime has occurred against a resident, they must report the incident. 2. Staff must report a suspicion of a crime to the state survey agency, local law enforcement, and/or the Ombudsman within a designated time frame by e-mail, fax or telephone. 3. The reporting individual will notify Local Law Enforcement immediately by phone and the LCT Ombudsman, Law Enforcement and Licensing Agency within 2 hours by fax when an incident involves abuse or serious bodily injury. During a review of the facility's undated P&P titled, Reporting Abuse to Facility Management , the P&P indicated the following: When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse was reported, the facility administrator, or his/her designee, may notify the following persons or agencies of such incident: a) The State licensing/certification agency responsible for surveying/licensing the facility; b) The local/State Ombudsman; 555881 Page 2 of 3 555881 07/18/2023 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0609 c) The Resident`s Representative (Sponsor) of Record; Level of Harm - Minimal harm or potential for actual harm d) Law Enforcement Officials; e) The Resident`s Attending Physician; and Residents Affected - Few f) The Facility Medical Director 555881 Page 3 of 3