Health inspection·November 15, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm 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: Residents Affected - Few 1. Ensure a Pre-admission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) assessment was resubmitted for one of 6 sampled residents (Resident 57). This deficient practice had the potential to place the resident at risk of not receiving necessary care and mental health services. Findings: During a review of Resident 57's face sheet, the face sheet indicated Resident 57 was admitted to the facility on [DATE]. The face sheet also indicated Resident 57 had diagnoses which included bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, activity levels, and concentration), depression (a serious mental health condition that involves a persistent low mood or loss of interest in activities), post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) and hypertension (a condition in which the pressure of your blood in your blood vessels is consistently too high). During a review of Resident 57's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/19/2024, the MDS indicated Resident 57's cognitive skills were severely impaired. The MDS also indicated Resident 57 required supervision with toileting hygiene, showering and upper/lower body dressing. During a review of Resident 57's PASRR Level 1 screening, the PASRR indicated Resident 57 did not have a mental health disorder. During a review of Resident 57's diagnosis list, the diagnosis list indicated Resident 57 was diagnosed with bipolar disorder, PTSD, and depression. During a concurrent interview and record review, on 11/14/2024, at 11:58 a.m., with the Resident Care Coordinator (RCC), the RCC stated PASRR's were conducted before admission to the facility or if a resident had a change of condition. The RCC stated Resident 57's PASRR Level 1 results were negative, indicating Resident 57 did not have a mental illness. The RCC stated Resident 57's diagnosis list indicated Resident 57 had a diagnosis of bipolar disorder upon admission on [DATE]. The RCC stated (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 6 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 11/15/2024 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)