Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clear View Convalescent Center during CMS and state inspections, most recent first.
A resident with severe dementia, CKD, and RA developed two stage 2 pressure ulcers on the buttocks, but the facility did not develop or implement a comprehensive person-centered care plan for the wounds. The DON confirmed no wound care plan interventions were created, even though the skin evaluation documented the ulcers and the facility policy required pressure areas to be entered in the care plan and weekly skin assessment.
A facility failed to accurately complete the MDS assessment for a resident by omitting Lasix, a diuretic medication, from the high-risk drug classes section. The resident, with hypertension and chronic kidney disease, required moderate assistance and had severely impaired cognitive skills. The MDS Nurse acknowledged the error, and the DON stressed the importance of accurate assessments for care planning. The facility's policy mandates accuracy certification, which was not adhered to, leading to incorrect data being sent to CMS.
The facility failed to create person-centered care plans for two residents, one with severe cognitive impairment and on diuretic medication, and another with PTSD. The absence of care plans for these conditions was confirmed by staff, highlighting a deficiency in addressing the residents' medical needs.
A facility failed to provide Trauma Informed Care to a resident with PTSD, who experienced triggers related to his Vietnam War service. Despite the resident's need for psychological counseling and group therapy, the facility did not offer these services, and no referral to a psychologist was made. Interviews with staff revealed a lack of documentation and interventions to address the resident's PTSD.
The facility failed to conduct an annual competency assessment for a Minimum Data Set Nurse (MDSN), with the last check being in December 2023. The Director of Nursing (DON) admitted to an oversight, and the facility lacked a policy for staff competency checks, potentially jeopardizing resident safety.
A resident reported being kicked by another resident, but the incident was not reported to authorities within the required timeframe. The facility's policy mandates immediate notification to law enforcement and reporting to the Ombudsman and CDPH within two hours for incidents involving abuse. The delay in reporting was due to an LPN being sidetracked, and the facility had a history of late reporting.
A resident with severe dementia experienced avoidable falls due to the facility's failure to conduct an IDT meeting and reassess fall risk after an initial fall. The resident's care plan lacked specific interventions for impulsive behavior, leading to another fall resulting in a femur fracture. Staff interviews indicated inadequate supervision and monitoring, contrary to facility policies.
Failure to Care Plan Stage 2 Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 37 after the resident developed two stage 2 pressure ulcers, one on the right buttock measuring 5 x 1.6 x 0.1 cm and one on the left buttock measuring 6 x 1.3 x 0.1 cm. During a concurrent interview and record review, the DON confirmed that care plans were not developed or implemented for the two stage 2 pressure ulcers and stated that care plan interventions were not created for their management. The facility’s policy indicated that when pressure areas were present, findings were to be documented in nursing progress notes, the care plan, and the weekly skin assessment. Resident 37 was admitted with diagnoses including severe dementia, chronic kidney disease, and rheumatoid arthritis. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated cognition was significantly impaired for memory and thinking, with cueing and supervision needed in daily tasks. Resident 37 required moderate assistance with bathing, toileting, and eating, and walked with a walker with setup and supervision from one staff member. The facility’s care plan record did not include interventions for the resident’s stage 2 pressure ulcers, despite the skin evaluation documenting the wounds.
Inaccurate MDS Assessment for Resident's Diuretic Medication
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of the sampled residents, Resident 23. The deficiency involved the omission of Lasix, a diuretic medication prescribed to Resident 23, from the MDS assessment under Section N0415, which is designated for high-risk drug classes. This error was identified during a review of Resident 23's records, which showed that Lasix was prescribed for hypertension but was not coded correctly in the MDS. The Minimum Data Set Nurse (MDSN) acknowledged the inaccuracy, stating that the omission was a result of a wrong entry and that the MDS assessment serves as a tool to recognize residents' problems and reflects the facility's plan of care. Resident 23 was admitted with diagnoses including hypertension and chronic kidney disease and was noted to have severely impaired cognitive skills, requiring moderate assistance with daily activities. The Director of Nursing (DON) emphasized the importance of accurate MDS assessments as they form the basis for the resident's plan of care. The facility's policy requires healthcare professionals to certify the accuracy of the MDS sections they complete, highlighting a lapse in adherence to this policy. The inaccurate data was transmitted to the Centers for Medicare and Medicaid Services (CMS), potentially affecting the facility's quality measures.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, Resident 23 and Resident 85, which resulted in a deficiency. For Resident 23, who was admitted with diagnoses including hypertension and chronic kidney disease, the facility did not create a comprehensive care plan addressing the use of diuretic medication, specifically Lasix. Despite the resident's severe cognitive impairment and need for moderate assistance with daily activities, there was no care plan to monitor the side effects of the diuretic medication or provide necessary interventions. This oversight was confirmed during an interview with the Minimum Data Set Nurse, who acknowledged the absence of a care plan for the diuretic medication. Similarly, the facility did not develop a care plan for Resident 85, who was diagnosed with PTSD, hypertension, and major depressive disorder. Although Resident 85 had intact cognitive skills and required supervision for daily activities, there was no care plan addressing the PTSD diagnosis or interventions to manage the resident's trauma. This was confirmed during an interview with the Social Service Designee, who noted the importance of a care plan for continuity of care. The facility's policy indicated that care plans should be updated as necessary, but this was not adhered to in these cases.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care (TIC) to a resident diagnosed with Post Traumatic Stress Disorder (PTSD), potentially leading to re-traumatization. The resident, who served in the Vietnam War, expressed that certain triggers, such as the sound of a phone ringing, reminded him of traumatic war experiences. Despite the resident's expressed need for continued psychological counseling and group therapy, which he had previously received through the Veterans Affairs, the facility did not offer these services. The resident's records indicated a need for psychological evaluation and follow-up, but no referral to a psychologist was made since his admission. Interviews with the Social Service Designee (SSD) and the Director of Nursing (DON) revealed that the facility lacked documentation and interventions to address the resident's PTSD. The SSD confirmed that there was no evidence of TIC being provided, and the DON acknowledged the absence of individual counseling and group therapy for the resident. The facility's assessment document indicated a commitment to addressing mental health needs, including PTSD, but this was not reflected in the care provided to the resident.
Failure to Conduct Annual Competency Assessment for Nursing Staff
Penalty
Summary
The facility failed to ensure that a competency assessment skills check was performed annually for one out of five randomly selected staff members. During an interview and record review, it was found that the Minimum Data Set Nurse (MDSN) did not have an annual competency assessment skills check on file, with the last check being conducted on December 6, 2023. The Director of Staff Development (DSD) acknowledged that competency assessments must be completed upon hire and annually, and that the Director of Nursing (DON) was responsible for completing these assessments for licensed nursing staff. The absence of an updated competency assessment could potentially jeopardize resident health and safety. Further interviews revealed that the DON admitted to an oversight in not completing the MDSN's annual competency assessment skills checklist. Additionally, the facility lacked a policy and procedure for staff competency checks, despite the Facility Assessment document indicating that competency skills evaluations should be conducted upon hire and annually. This deficiency highlights a lapse in the facility's process to ensure that nursing staff possess the necessary skills to provide safe and effective care to residents.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its policy and procedure for reporting suspected crimes under the Federal Elder Justice Act. This deficiency was identified when Resident 56 reported being kicked in the stomach by Resident 14 approximately two weeks prior. The facility's policy requires immediate notification to local law enforcement and reporting to the Long-Term Care Ombudsman and the California Department of Public Health (CDPH) within two hours when an incident involves abuse or serious bodily injury. However, the report was delayed, and the incident was not reported to the appropriate authorities in a timely manner. Resident 56, who has a history of cerebral infarction and vascular dementia, reported the incident to Licensed Vocational Nurse 3 (LVN 3) during a medication pass observation. Despite being a mandated reporter, LVN 3 did not report the allegation to the Director of Nursing (DON) or the Administrator (ADM) immediately, citing being sidetracked and busy with other tasks. The facility's policy mandates that any allegation of abuse should be reported immediately or within two hours to ensure the safety and well-being of residents. The DON and ADM were made aware of the incident the following day, and the SOC 341 form was completed and faxed to the Ombudsman and CDPH. The delay in reporting was acknowledged by both the DON and ADM, who emphasized the importance of timely reporting to prevent further abuse and ensure prompt investigation by the authorities. The facility had been cited in the past for late reporting of abuse allegations, highlighting a recurring issue with compliance in this area.
Failure to Prevent Avoidable Falls in a Resident with Severe Dementia
Penalty
Summary
The facility failed to ensure that a resident was free from avoidable falls by not conducting an Interdisciplinary Team (IDT) meeting following a fall on 11/12/2024, as indicated in the Change of Condition (COC) assessment. The resident, who had severe dementia and other medical conditions, fell on his right knee while out of the facility at an appointment. Despite the COC assessment indicating that an IDT meeting was required, it was not conducted, which was a missed opportunity to review and adjust the resident's care plan to prevent further falls. Additionally, the facility did not reassess the resident's Fall Risk Assessment after the fall on 11/12/2024. The resident had a history of severe cognitive impairment and required supervision for activities of daily living. The lack of reassessment meant that the resident's care plan was not updated to reflect the increased risk of falls, and necessary interventions were not implemented. This oversight contributed to the resident experiencing another fall on 1/1/2025, resulting in a fracture of the right femur. The facility also failed to develop a comprehensive person-centered care plan to address the resident's impulsive behavior and tendency to overestimate abilities. The care plan did not specify the type of supervision and monitoring required for the resident's safety, particularly during the daytime or while up in a chair. Staff interviews revealed that the resident was left unsupervised, which led to the unwitnessed fall. The facility's policies on fall prevention and dementia care were not adequately followed, as evidenced by the lack of specific interventions and monitoring for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gardena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clear View Sanitarium | 0 mi | ★★★★★ | 10 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 0.3 mi | ★★★★★ | 13 | 0 |
| Kei-ai South Bay Healthcare Center | 0.7 mi | ★★★★★ | 17 | 0 |
| Gardena Convalescent Center | 0.8 mi | ★★★★★ | 16 | 0 |
| Rosecrans Care Center | 1.1 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.