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 Page 1 of 6 555881 555881 11/15/2024 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a PASRR should had been resubmitted for Resident 57. The RCC stated the risk of not resubmitting a PASRR for a resident could result in a lack of mental health resources that a resident need. During a interview, on 11/15/2024 at 1:03 p.m., with the Director of Nursing, the DON stated the RCC was responsible for completing the PASRR for residents. The DON stated PASRRs are conducted prior to admission and for any change of condition. The DON stated a PASRR should had been resubmitted for Resident 57. The DON stated the risk of not resubmitting a PASRR for a resident could result in not providing the best care possible for the resident and a lack of care. During a review of the facility's policy and procedures, titled Pre-admission Screening and Resident Review (PASRR) Policy, undated, the policy and procedure indicated, The facility will refer all Level 2 residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a Level 2 review upon a significant change in status assessment to the State PASRR representative. 555881 Page 2 of 6 555881 11/15/2024 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure Resident 30 was not prescribed Seroquel (an anti-psychotic medication used to treat mental illness) to control dementia (condition where there is a decline in mental abilities and memory) symptoms. This deficient practice put Resident 30 at risk of an adverse reaction (bad outcome) from taking an anti-psychotic without a diagnosis of a mental illness. Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes (high blood sugar), and hypertension (high blood pressure). During a review of Resident 30's History and Physical (H&P), dated 4/28/2023, the H&P indicated Resident 30 does not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 10/24/2024, the MDS indicated Resident 30's cognition (ability to gain knowledge and understand) was moderately impaired. Resident 30 does not have indicators of psychosis (symptoms that make it difficult to determine reality). There are no behavioral symptoms. During a review of Resident 30's Physician Orders, dated 11/14/2024, the orders indicated Resident 30 is taking Seroquel 50 mg three times a day for dementia with behavioral disturbances manifested by striking out. During a concurrent interview and record review on 11/15/2024 at 2:13 p.m. with Registered Nurse (RN) 1, Resident 30's medical record was reviewed. The record indicated Resident 30 does not have a diagnosed mental illness. RN1 stated Resident 30 takes Seroquel to control dementia behaviors. RN1 stated giving an anti-psychotic to an elderly person with dementia can be harmful because it increases their risk of falls. 555881 Page 3 of 6 555881 11/15/2024 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to: Residents Affected - Few 1. Ensure that the medication storage room had a room thermometer that was monitored, and the readings recorded in a room temperature log to ensure a safe temperature range for medication storage. This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. Findings: During a concurrent observation and interview, on November 15, 2024, at 9:00 am of the medication room with the Director of Nursing (DON), there was no room thermometer to monitor the temperature. The DON stated there usually is a thermometer in the medication storage room. DON looked around the room and stated, The room was reorganized, and I do not know where it is now. When the surveyor asked if there is a logbook to record room temperatures, the DON stated, We do not have a logbook for room temperatures, only the refrigerator has a log. The DON stated they would request maintenance to come check the room temperature if it felt too warm or cold. During an observation, on November 15, 2024, at 9:22 am, Administrator (ADM) 1, opened a new package containing a room thermometer and hung it on a bulletin board near the medication room door. During a review of the facility's policy and procedures titled Storing Drugs, indicated Keep drugs requiring storage at 'room temperature' at no less than 15 degrees Celsius (59 degrees Fahrenheit) or more than 30 degrees Celsius (86 degrees Fahrenheit). 555881 Page 4 of 6 555881 11/15/2024 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to: Residents Affected - Few 1. Ensure the walk-in refrigerator did not contain a spoiled bag of cilantro. This deficient practice had the potential to result in food borne illness (sickness from eating food with harmful bacteria) for any resident consuming the cilantro. Findings: During a concurrent observation and interview on 11/12/2024 at 9:13 a.m. with the Dietary Supervisor (DS) in the walk-in refrigerator, a bag of cilantro was found with brown leaves and brown liquid collecting in the bottom of the bag. The bag of cilantro was labeled with a received date of 10/28/2024. The DS stated, It's expired. You should remove it. You can't eat it because it's spoiled. The DS cannot state what may happen if a resident eats the expired food. 555881 Page 5 of 6 555881 11/15/2024 Clear View Sanitarium 15823 So. Western Ave. Gardena, CA 90247

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to: 1. Ensure the dumpsters were kept closed and all trash was contained. Residents Affected - Few This deficient practice had the potential to attract rodents to the trash area. Findings: During a concurrent observation and interview on 11/12/2024 at 9:05 a.m. with the Dietary Supervisor (DS) at the dumpster area, both dumpsters were open, one was overflowing. Three uncovered gray bins containing loose trash were sitting in front of the dumpsters. The DS stated the dumpsters should be closed at all times. The DS further stated, by leaving the dumpster open could attract animals. 555881 Page 6 of 6