Clear View Convalescent: Pressure Ulcer Care Plan Failures - CA
Inspectors documented the lapse during a March 2026 survey. The resident at the center of the finding, identified in records as Resident 37, had been living at the facility since late 2025. Alongside dementia described as severe, Resident 37 carried diagnoses of chronic kidney disease and rheumatoid arthritis, a combination that complicates healing and increases the stakes of any wound left unmanaged.
A history and physical from December 2025 noted that Resident 37 lacked the capacity to understand and make decisions. A resident assessment completed the following day found significantly impaired memory and thinking, with Resident 37 needing cueing, supervision, and moderate hands-on help from staff for bathing, toileting, and eating. Resident 37 could walk with a walker, but only with setup and supervision from a staff member.
By March 11, 2026, a weekly skin evaluation had found two stage 2 pressure ulcers, one on the right buttock measuring roughly two inches long and less than an inch wide, the other on the left buttock slightly larger. Stage 2 means the skin has already broken down past the surface layer, leaving a shallow open wound. At that point, a resident who cannot reposition independently, cannot communicate distress clearly, and whose kidneys are already struggling to filter waste is in a situation where an unmanaged wound can deteriorate quickly.
No care plan was written. Not for the right buttock. Not for the left.
On March 26, an inspector sat down with the Director of Nursing and reviewed Resident 37's care plans directly. The Director of Nursing confirmed what the records showed: no care plan interventions had been created for either pressure ulcer. The Director of Nursing then said, plainly, that not having a care plan put Resident 37 at risk for worsening pressure ulcers and that the wounds could get worse.
That acknowledgment came fifteen days after the wounds were first documented.
The facility's own written policies described exactly what was supposed to happen. One policy on pressure sore and wound management stated that when pressure areas were found, the findings were to be entered in nursing progress notes, the care plan, and the weekly skin assessment. A separate policy on care planning listed a skin break as an example of a short-term problem requiring a short-term care plan. The documentation of the wounds existed. The weekly skin note was there. The care plan was not.
Inspectors rated the violation at a level of minimal harm or potential for actual harm, affecting a small number of residents. The finding was cited as a failure to develop and implement a comprehensive, person-centered care plan.
For Resident 37, the gap meant that for at least the two weeks between the March 11 skin evaluation and the March 26 inspection interview, staff had no formal, documented roadmap for managing either wound. No written interventions specifying repositioning schedules, pressure-relieving surfaces, wound treatment protocols, or goals for healing. In a resident who cannot advocate for themselves, cannot describe pain or changes in a wound, and requires staff assistance for nearly every daily task, the care plan is often the only mechanism ensuring that what needs to happen actually gets communicated from one shift to the next.
The Director of Nursing confirmed it wasn't there. The wounds, as of the inspection, remained open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clear View Convalescent Center from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
CLEAR VIEW CONVALESCENT CENTER in GARDENA, CA was cited for violations during a health inspection on March 27, 2026.
Inspectors documented the lapse during a March 2026 survey.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.