Clear View Sanitarium

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation were practiced in the kitchen when:1 dented can of pineapple chunks was mixed with regular non-dented cans in the dry storage area.6 cups of 8 ounces ([oz.] small unit of weight measurement) of thickened water and 1 cup of 8 oz of orange juice was on the tray with no use by date label. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 70 out of 70 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure written Notice of Proposed Transfer/Discharge contained the required content elements for one of three sampled residents (Resident 75). The deficient practice had the potential to compromise the resident's due process rights related to discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly (every 3 months) Minimum Data Set Assessment ([MDS] - a resident assessment tool) for one of one sampled resident (Resident 4) was completed within the required timeframe. This deficient practice had the potential to result in a billing error and inaccurate data on Resident 4's care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of 18 sampled residents (Resident 3) by failing to ensure Resident 3's use of antibiotic (a drug used to treat infections) was encoded in the recent MDS assessment. This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review ([PASARR] - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 screening (a mandatory preliminary screening required for all individuals seeking admission to a Medicaid-certified nursing facility) was completed and re-submitted for one of four sampled residents (Resident 3). This failure had the potential for Resident 3 not being appropriately identified for further evaluation of serious mental illness leading to resident not receiving necessary specialized services, treatment planning interventions, or appropriate placement.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan interventions were implemented to ensure a dialysis (a treatment to cleanse the blood of wastes and extra fluid artificially through a machine when the kidney(s) have failed) emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the event of an emergency) was always available at bedside for one of one sampled resident (Resident 8). This deficient practice has the potential to result in staff's inability to manage and control the bleeding from Resident 8's dialysis access site in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to review, update, and revise the care plan to address the use of bolster pads (a soft barrier along the edges of the bed, reducing the risk of rolling out of bed) for one of one sampled resident (Resident 1). This deficient practice has the potential to affect the delivery of necessary care, treatment, and services for Resident 1.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of the trash dumpsters was closed and not overfilled. This deficient practice has the potential for harboring and feeding of pests.

Inspectors wroteBased on interview and record review, the facility failed to: 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview, the facility failed to: 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.

Inspectors wroteBased on observation and interview, the facility failed to: 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.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure the dumpsters were kept closed and all trash was contained. This deficient practice had the potential to attract rodents to the trash area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use one unopened browned turkey breast before its use fresh or freeze by date on 10/6/2023 or throw it after the safe time limit of 14 days of thawing (a process of taking a frozen product from frozen to unfrozen state) and refrigeration storage time on 11/1/2023 in the walk-in refrigerator. This failure had the potential to result in dietary staff serving the browned turkey breast to residents and cause spoiled or unsafely stored food symptoms of vomiting and diarrhea to residents.