Clearview Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used acceptable infection control procedures and practices for wound care for two residents (Residents #1 and #55) out of two sampled residents, one resident (Resident #4) for catheter (a flexible tube placed in the bladder to drain urine) care out of one sampled resident, and one resident (Resident #6) with a gastrostomy tube (g-tube - a medical device surgically placed through the abdomen directly into the stomach to deliver nutrition, fluids, and medication when oral intake is unsafe or insufficient) out of one sampled resident. The facility also failed to ensure laundry was processed in a way to limit the spread of infections. This practice could potentially affect all residents. The facility census was 62. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff maintained or enhanced the quality of life for two residents (Residents #8 and #54) and failed to maintain the dignity of one resident (Resident #55) when left exposed during care out of 16 sampled residents. The facility's census was 62. The facility did not provide a dignity policy. 1. Observation on 03/02/26 at 12:11 P.M., of Resident #8 showed:- The resident sat in the hall and asked two different staff that passed by for a cup of coffee; - No staff acknowledged the resident. Observation on 03/02/26 at 12:31 P.M., showed:- The resident asked Certified Nursing Assistant (CNA) J if he/she could have a cup of coffee as CNA J walked by;- CNA J responded in a loud and stern voice, No, the kitchen is closed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for the risk of entrapment, review the possible risks and benefits of the side rails prior to installation or use, and the facility failed to obtain informed consent of the side rails prior to use for four residents (Residents #1, #6, #52, and #55) out of four sampled residents. The facility census was 62. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for the risk of entrapment, review the possible risks and benefits of the side rails prior to installation or use, and the facility failed to obtain informed consent of the side rails prior to use for four residents (Residents #1, #6, #52, and #55) out of four sampled residents. The facility census was 62. The facility did not provide a side rail assessment policy. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture (broken bone) of the left leg, pain, muscle weakness, and chronic obstruction pulmonary disease (COPD - a long-term chronic airway disease);- Cognition moderately impaired;- No documentation of a side rail assessment or informed consent for the use of side rails. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for four out of four days. The facility census was 62. The facility did not provide a policy on nurse staff posting. Observations on 03/02/26 at 12:05 P.M., 03/03/26 at 9:00 A.M., 03/04/26 at 8:45 A.M., and 03/05/26 at 12:30 P.M., showed:- Daily nurse staffing posted on the east end of the facility near the nurses' station;- No daily nurse staffing posted at the main entrance of the facility or at the west end area of the facility;- Daily nurse staffing not posted in a prominent place readily accessible to all residents and visitors. During an interview on 03/05/26 at 1:30 P.M., Certified Nurse Aide (CNA) K said the nursing staff information had always been posted on the east end of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for four residents (Residents #1, #6, #52 and #55) out of four sampled residents. The facility census was 62. The facility did not provide a side rail inspection policy. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture (broken bone) of the left leg, pain, muscle weakness, and chronic obstruction pulmonary disease (COPD - a long-term chronic airway disease);- No maintenance inspection for the side rail. Observations on 03/02/26 at 1:10 P.M., and 03/03/26 at 10:00 A.M., of the resident's bed showed:- A side rail in the upright position on both half sides of the resident's bed and moved with minimal effort. Observation on 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights were placed within reach to meet resident needs for five residents (Residents #5, #6, #52, #54 and #67) out of 16 sampled residents and one resident (Resident #12) outside the sample. The facility census was 62. The facility did not provide a call light policy. 1. Observations on 03/02/26 at 9:56 A.M., and 2:13 P.M., 03/03/26 at 8:33 A.M., and 12:47 P.M., and 03/04/26 at 2:28 P.M., of Resident #67 showed:- The resident lay in bed and the call light out lay on the floor out of the resident's reach;- The resident sat in a Geri-chair (a specialized, heavy padded recliner) and the call light lay on the floor out of the resident's reach. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions), Abuse (infliction of physical, sexual or emotional injury/harm), and Neglect (failure to provide necessary services for an adult's safety or health) prevention for two Certified Nurse Aides (CNA) (CNA C and CNA D) out of two sampled CNAs. The facility census was 62. The facility did not provide a nurse aide in-service education policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to respond or act upon grievances, and failed to keep documentation of inventory for two residents (Residents #23 and #48) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, Grievance Protocol, undated, showed: - The purpose of the grievance/complaint report and grievance log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline; - The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation; - Grievance complaint should be filled out for resident articles that are lost or cannot be located; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order for code status for two residents (Residents #14 and #38) and consistently document a resident's code status with Full Code (cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) or Do Not Resuscitate (DNR - does not want CPR) for one resident (Resident #35) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, DNR Protocol, not dated, showed: - The Social Services Designee (SSD) will be responsible to print all DNR order forms on lavender paper to be placed in the admission packet; - Once the DNR form is signed by the resident or legal representative it is to be signed by the physician; - The SSD will then complete the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 59. The facility did not provide a homelike environment policy. 1. Observations on 12/03/24 at 2:42 P.M., and 12/04/24 at 9:20 A.M., of the 100 Hall showed: - A seat cushion cover worn with several peeled areas on a chair next to the bed near the door in room [ROOM NUMBER]; - Several areas of wallpaper peeled with exposed sheetrock located behind the bed near the window in room [ROOM NUMBER]; - A seat cushion cover worn with several peeled areas on a chair next to the bed near the door in room [ROOM NUMBER]; - Dark scuff marks and a three inch (in.) area of exposed sheetrock and peeled paint on the wall next to the door in room [ROOM NUMBER]. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for two residents (Residents #4 and #51) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, MDS and Care Planning Guidelines, revised 10/01/15, showed: - It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI - a tool used to assist facility staff to gather defined information on a resident's strengths and needs) Manual, any published interim RAI manual errata (error) documents, and applicable federal guidelines as the authorative guide for completion of MDS, care area assessments (CAAs) and resident care planning; - The policy did not address the accuracy of MDS assessments. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder, to determine the level of care needed) for two residents (Residents #4 and #43) out of two sampled residents. The facility census was 59. The facility did not provide a policy for a PASARR. 1. Review of Resident #4's medical record showed: - An admission date of 03/16/21; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and post traumatic stress disorder (PTSD - psychological distress following a traumatic event); - No documentation of the required level one PASARR screening upon admission to the facility. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, monitor, and modify interventions to maintain acceptable parameters of nutritional status for one resident(Resident #14) out of two sampled residents. The facility census was 59. Review of the facility's policy titled, Weight Champion Program, not dated, showed: - Each community should designate a weight champion to assist in the oversight and monitoring of residents that have or are at risk for weight loss; - The purpose of this program is to take a proactive stance against weight loss and collaborate to decrease weight loss numbers; - The weight champion will be responsible for keeping the weight variance report from Matrix, as well being custodian of the daily, weekly and monthly facility weight lists; - The champion will review for completion during the next stand up meeting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 37 opportunities with three errors made, resulting in an error rate of 8.11% for three residents (Residents #20, #34 and #38) out of eleven sampled residents. The facility's census was 59. Review of the facility's policy titled, Specific Medication Administration Procedures, dated July 2021, showed: - Prime insulin pen prior to use; - Dial up two units; - Hold pen upright and push the button on the end of the pen so a small drop of insulin appears; - Dial insulin to the desired insulin dose to be administered to the resident. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for one resident (Resident #6) out of one sampled resident. The facility failed to use proper hand hygiene during blood sugar testing for four residents (Residents #3, #10, #20 and #38) out of four sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility census was 59. Review of the facility's policy, titled, Enhanced Barrier Precautions to Infection Control Guidelines, updated 2024, showed: -To prevent broader transmissions of multi-drug resistance organisms (MDROs) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for two certified nurse assistants (CNA) (CNA A and CNA B) of two nurse aides sampled. The facility census was 59. The facility did not provide a nurse aide in-service policy. Review of the facility assessment, revised 02/06/24, showed: - Required in-service training for nurse's aides: 1. Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; 2. Include dementia management training and resident abuse preventions training; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure at least one person had completed specialized training in infection prevention and control for the Infection Preventionist (IP) (a professional who assures healthcare workers and residents are doing everything possible to prevent infection) position. This had the potential to affect all residents in the facility. The facility census was 52. Review of the facility's policy titled, Infection Prevent and Control Program, dated 02/07/23 showed the IP is qualified to conduct infection prevention and control activities as a result of education, training and experience (he/she will complete the Centers for Disease Control and Prevention (CDC) Long Term Care Infection Preventionist module). The facility did not provide documentation for any staff members that had completed the specialized training for the IP position. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of a Level I Preadmission Screening and Resident Review (PASARR) (a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for two residents (Residents #38 and #41) out of four sampled residents. The facility's census was 52. The facility did not provide a policy regarding PASARR. 1. Review of Resident #38's medical record showed: - An admission date of 03/08/21; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for six residents (Residents #13, #14, #18, #21, #31, and #38) out of 13 sampled residents. The facility census was 52. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed: - An individualized comprehensive care plan includes measurable goals and time frames that meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Resident #18 and #31) out of two sampled residents. The facility census was 52. Review of the facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed: - Care of the arteriovenous (AV) shunt/fistula/graft (a surgical connection between an artery and a vein): Keep the area clean and dry; Feel for the thrill (vibration caused by blood flowing through fistula, can be felt by placing finger above the fistula incision site) sensation daily; Inspect the access for redness, swelling, or warmth; Avoid constrictive clothing or jewelry that may bind the access site; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for two residents (Resident #21 and #38) with a diagnosis of Post-Traumatic Stress Disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 52. The facility did not provide a PTSD policy. 1. Review of Resident #21's medical record showed: - admitted on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the pharmacist's gradual dose recommendations (GDR) for two residents (Resident #9, and #49) out of five sampled residents. The facility's census was 52. Review of the facility's policy titled, Drug Review, not dated, showed: - Antipsychotic (a medication used to treat psychosis or the loss of connection to reality) drugs should only be given when necessary to treat a specific condition; - Determine the most acceptable time frame to attempt reduction of the drug dosage from behavior evaluation; - Notify the physician of the findings and recommendations, obtain an order for attempts at reduction; - Instruct the resident; - Document the reductions and behavior pattern exhibited; - Report progress or lack of progress to the physician. 1. Review of Resident #9's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 52. The facility did not provide a policy. Review of the facility's current employee list, dated 10/09/23, showed a hire date of 06/20/22 for the Dietary Manager (DM). During an interview on 10/17/23 at 8:58 A.M., the DM said he/she had been the DM since June 2022 and was not certified yet. Some certification classes had been taken, but he/she had not passed the certification test yet. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual competencies of dementia care (care of a resident with an impaired ability to remember, think, or make decisions), and 12 hours of training for two Certified Nurse Aides (CNA) (CNA C and CNA D) out of two sampled CNAs, which had the potential to affect all residents. The facility's census was 52. The facility did not provide a policy in regards to the required annual competencies for CNAs. 1. Review of CNA C's in-service record showed: - A hire date of 08/13/22; - No documentation of the annual Dementia Care training provided for August 2022 through August 2023; - No documentation of 12 hours of training provided for August 2022 through August 2023. 2. Review of CNA D's in-service record showed: - A hire date of 04/25/22; [...]