Clear View Convalescent Center

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled residents (Resident 37) after Resident 37 developed two stage 2 pressure ulcers/injuries (partial-thickness loss of skin, presenting as a shallow open sore or wound). This deficient practice has the potential to result in Resident 37 experiencing worsening skin breakdown, infection and delayed healing. FindingsDuring a review of Resident 37's Admitting and Discharge record, the Admitting and Discharge record indicated Resident 37 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement its undated Policy and Procedure (P&P) titled, Reporting Suspected Crimes Under The Federal Elder Justice Act which indicated the reporting individual will notify local law enforcement immediately by phone and the Long Term care Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility) and licensing agency (California Department of Public Health) within 2 hours by fax when an incident involves abuse or serious bodily injury, after Resident 14 was alleged to have kicked Resident 56 in the stomach, approxiamately two weeks ago. This deficient practice had the potential to place Resident 56 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 19 sampled residents (Resident 23) by failing to: 1. Ensure Resident 23's Lasix (a diuretic drug that helps reduce the amount of excess fluid in the body by increasing the amount of urine produced) medication was coded as diuretic and reflected in the MDS assessment under Section N (N0415) High-Risk Drug Classes) Medications. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to facility's inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan for two of 19 sampled residents (Resident 23 and Resident 85) by failing to: 1. Develop a comprehensive care plan addressing Resident 23's use of diuretic (drug that helps reduce the amount of excess fluid in the body by increasing the amount of urine produced) medication. 2. Develop a comprehensive care plan addressing Resident 85's diagnosis of Post Traumatic Stress Disorder ([PTSD] - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 23 and Resident 85.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 85) with Post Traumatic Stress Disorder ([PTSD] - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) received Trauma Informed Care ([TIC] - an intervention and approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This deficient practice had the potential for the staff's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) for Resident 85.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks performed annually for one out of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from an avoidable fall when the facility: 1. Did not conduct an Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) meeting as indicated in the Change of Condition (COC) assessment dated [DATE], following Resident 1 ' s fall on 11/12/2024. 2. Did not reassess Resident 1 ' s Fall Risk Assessment following Resident 1 ' s fall on 11/12/2024. 3. Did not develop a comprehensive person-centered care plan to address Resident 1 ' s impulsive behavior, tendency to overestimate abilities and get up without asking for assistance during the daytime or while up in chair and did not specify the type of supervision and monitoring Resident 1 required for safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights or light strings were accessible for two of four sampled residents (Residents 60 and 81). This deficient practice had the potential for avoidable harm as the two residents would not be able to use their call light to request assistance if needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe food storage and food date and labeling practices in the kitchen: 1. The facility failed to date split peas after opening. 2. The facility failed to date individual cups of prune juices. This deficient practice had the potential to result in harmful bacteria growth that could lead to foodborne illness in 92 residents who will receive food and drinks from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice of Non-Coverage (ABN) forms to the Health Care Responsible Party for two of two sampled residents (Resident 22 and 26). This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file an appeal and unknowingly paying for non-covered care expenses.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Level I Pre-admission screening and resident review (PASARR - a mental health assessment tool) was submitted to the state-designated authority in a timely manner for one out of five residents (Resident 76). This failure had the potential to result in Resident 76 not receiving appropriate mental health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Check the blood pressure prior to administering Propranolol (blood pressure lowering medication) and Spironolactone (medication that removes extra fluid from the body). This deficient practice had the potential to result in a dangerously low blood pressure for one of five sampled residents (Resident 91).

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory test ordered by the physician was available in the resident's clinical records and results reported to the physician in a timely manner for one of one sampled resident (Resident 80). This deficient practice had the potential for Resident 80 not receiving necessary medical treatment.