Providence Little Co of Mary Transitional Care Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 90) received a self administration assessment, education, and a physician order prior to self administering an albuterol puff inhaler (a medication used for shortness of breath). This failure resulted in Resident 90 keeping and using an albuterol inhaler at the bedside and placed the resident at risk for improper medication use and potential unsafe clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable and safe environment when the overhead light in Resident 17's room was found to be non-functional, providing inadequate lighting for daily activities. This failure resulted in Resident 17's having limited visibility during evening hours, increasing the risk of falls, injury, or difficulty accessing the call light.

Inspectors wroteBased on interviews, and record review the facility failed to ensure one of three sampled residents (Resident 69) had timely physician notification and appropriate nursing interventions when Resident 69's experienced a change of condition([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) when Resident 69 blood pressure (a measurement of the force exerted by circulating blood against the wall of the arteries) dropped to 98/43 millimeters of mercury (mm/Hg) on [DATE] at 3:57 p.m. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure effective and appropriate pain management for one of one sampled residents (Resident 40). The facility failed to:1. Ensure pain medications were administered according to the physician's orders and pain level parameters.2. Ensure appropriate assessment and communication with the physician regarding the resident's pain. This failure placed Resident 40 at risk for receiving medication stronger than clinically indicated and experiencing adverse side effects (unwanted, uncomfortable, or dangerous reactions to medication).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control measures were observed for one of three sampled residents (Residents 87 ). The facility failed to:1. Ensure facility staff wore required personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards) prior to providing care to Resident 87, who was on enhanced barrier precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO], microorganisms resistant to one or more classes of antimicrobial agents) for a pressure injury (PI-injury to the skin and underlying tissue caused by prolonged pressure). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 40) had a functioning call light readily accessible to request assistance. This failure placed Resident 40, who is at high risk for falls, at increased risk for injury due to the inability to summon staff assistance.

Inspectors wroteBased on interview and record review, the facility failed to implement the discharge plan to ensure a safe discharge for one of three residents (Resident 1) by not providing the resident with a written discharge notice 30 days prior to discharge. This deficient practice placed Resident 1 at risk for an unsafe discharge. During a review of Resident 1's History and Physical (H&P), dated 9/26/2025, the H&P indicated the facility admitted Resident 1 on 9/25/2025 for rehab with diagnoses that included failure to thrive (a syndrome characterized by a rapid decline in physical, functional, and cognitive abilities), right renal mass (an abnormal growth in the kidney), and chronic diastolic congestive heart failure (when the left ventricle becomes stiff and cannot relax to fill with enough blood, leading to high pressure and fluid buildup). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was updated for one of three sampled residents (Resident 1) who demonstrated the behavior of uncovering self, which was necessary to maintain Resident 1's dignity and rights. This deficient practice resulted in Resident 1 not receiving specific interventions to address the uncovering behavior, leading to exposure of private areas and a failure to maintain Resident 1's dignity and rights. [...]

Inspectors wroteBased on interviews and record review, the facility failed to obtain informed consent and provide written notice for one of two sampled residents (Resident 1), prior to a facility-initiated room change for Resident 1 in accordance with the facility's policy and procedure on resident rights. This deficient practice had the potential to result in Resident 1's emotional distress or physical decline due to Resident 1 becoming unhappy with their living arrangements or developing distrust in the facility. Based on interview and record review, the facility failed to obtain informed consent and provide written notice for one of two sampled residents (Resident 1), prior to a facility-initiated room change for Resident 1 in accordance with the facility's policy and procedure on resident rights. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records updated to show documentation that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed and written information was provided to the residents and /or responsible parties for two of five residents (Residents 89 and 195). This failure violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistant's (CNA's) annual skills competencies were completed for CNA 2 and CNA 3 . These failures had the potential to put the resident's safety at risk during care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 20's physician orders for losartan (a medication used to treat hypertension [HTN - high blood pressure]) and hydrochlorothiazide (a medication used to treat HTN) indicated hold parameters for medications based on resident's blood pressure readings, affecting one of five sampled residents reviewed for medication administration. This deficient practice had the potential to result in medication errors, blood pressure abnormalities and heart complications for Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of five reviewed residents for medication errors (Residents 95 and 296) by failing to: a. Administer Resident 95's Vimpat ([generic name - lacosamide] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), gabapentin (a medication used to treat nerve pain and seizures), levetiracetam (a medication used to treat seizures) and metoprolol tartrate (a medication used to treat high blood pressure), within one hour before or after the scheduled administration time of 9:00 a.m., per facility's policy and procedure (P&P) titled, Medication Management, dated 7/2023. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 196's medical information was kept private from unintended public view, affecting one of five residents observed during survey task observations. This deficient practice had the potential for anyone to access Resident 196 medical records that are confidential.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 20) had side rails (bars or rails attached to the sides of a bed) were in up position. This failure had the potential to put Resident 20 at risk for injuries such as falls, strangulation and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 2 crushed and administered each oral medication separately for one of five sampled residents (Resident 94) during medication administration observation. This failure had the potential to place Resident 94 at risk for drug interactions (occur when two or more drugs taken simultaneously affect each other's actions in the body) or intolerability to one or more medications without possibly knowing which medication caused intolerability.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 95) received appropriate services to meet resident's behavioral health care needs by failing to: 1. Ensure the psychiatric services( type of mental health care that focuses on diagnosing and treating mental illness) were provided to Resident 95 who was prescribed Ativan (Lorazepam- drug used to treat anxiety) and Seroquel ( Quetiapine- drug to treat depression) after manifesting confusion, anxiety and climbing out of bed. Resident 95 had diagnoses of anxiety and depression and was on Prozac(Fluoxetine- drug used to treat depression), Ambien ( drug used treat insomnia) and Valium ( medicine used to treat anxiety disorder). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled Residents (Resident 95 and Resident 293) were free of unnecessary psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) by failing to: A. Assess appropriateness of Resident 95's psychotropic medications and reevaluated when Resident 95's had increased anxiety (emotion characterized by feelings of tension, worried thoughts) on 3/17/2025. B. Document indication for the use of Seroquel (medication that treats several kinds of mental health conditions including schizophrenia [a mental illness that is characterized by disturbances in thought]) and Ativan (medication to treat anxiety) for Resident 95 and Resident 293. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, secured, and limited access to Resident 20's, Resident 94's and Resident 296's prepared medication that was left at the bedside and Resident 95's gabapentin (a medication used to treat nerve pain), affecting four of five residents sampled during medication administration. This deficient practice increased the risk of unintended access to medications, potential for misuse and medication errors for Residents 20, 94, 95 and 296.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures by not ensuring staff perform hand hygiene when food server (FSW) failed to wash her hands when entering leaving the kitchen area. This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of one sampled resident (Resident 1), a morse fall risk assessment (a tool used to assess a resident's risk of falling in a hospital setting) was completed every shift in accordance with the facility's policy regarding Fall Risk Assessment and Prevention. These deficient practices had the potential to cause a delay in determining Resident 1's fall assessment and/or provision of proper fall intervention needed, which could result in fall that could cause Resident 1 harm or even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1) Label and date an opened container of carrots, and bread rolls, and discard stored expired cooked chicken meat and expired cooked beef meat. 2) Ensure the executive chef handed food to [NAME] 1 while wearing gloves. 3) Ensure [NAME] 2 did not repeatedly touch the serving plate during food preparation without gloves. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for the vulnerable residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the professional standards of practice in administering intravenous ([IV] administered through vein) medications when the IV antibiotic bags for 3 of 3 sampled residents (Residents 99, 103 and 106) were not labeled with resident's names, date, time and signature of staff administering, as indicated in their facility's policy and procedures (P&P) IV bag Preparation, dated 8/21/2023. This deficient practice had the potential for medication errors and to result in severe drug reactions, anaphylactic (a severe immune system reaction) shock, requiring hospitalizations or even death.

Inspectors wroteBased on interview and record review, the facility failed to implement infection control measures by not ensuring the following for five out of seven sample residents (Residents, 11,17, 198 and 201): 1. Ensure Resident 198's peripherally inserted central catheter (PICC) line (a thin flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) dressing was changed weekly. 2. Change gloves and perform hand hygiene while administering medication and wiping down equipment for Residents 11, 17, and 201. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a cover (dignity bag) for a urine collection bag for one of two sampled Residents (Resident 32). This deficient practice had the potential to negatively affect Resident 32's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure residents' activated call light's (requests for assistance) were answered promptly for one of three sampled residents (Resident 255). This deficient practice had the potential to cause delay in meeting Resident 255's need. During a review of Resident 255's admission record note dated 3/1/2024, the note indicated Resident 255 was admitted on [DATE] with diagnoses including hypertension (high blood pressure), history of falls, and a lumbar compression fracture (when one or more bones in the spine weaken and crumble). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for one out of one sampled resident (Resident 33) when Registered Nurse (RN) 8 failed to administer the full ordered dose of Enoxaparin (a medication used to prevent blood clots that comes in a prefilled syringe). This deficient practice had the potential for Resident 33 to get blood clots due to not getting the prescribed amount of medication. During a review of Resident 33's admission note dated 2/9/2024, the note indicated Resident 33 was admitted on [DATE] with diagnoses including liver cirrhosis (scarring of the liver)/hepatitis C (inflammation of the liver), right tibia (shin bone) and fibula (calf bone) fracture, left calcaneal (heel bone) fracture, and anemia (not having enough healthy red blood cell to carry oxygen to the body's tissue). [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide oxygen therapy for one (1) of three (3) sampled residents (Resident 1). Resident 1 had a change of condition, on 11/27/2023 at 8:08 a.m., and staff did not provide oxygen to Resident 1 prior to the arrival of Emergency Medical Services (EMS, 911). This deficient practice resulted in Resident 1 not receiving oxygen therapy until Emergency Medical Services (911) arrived on 11/27/2023 at 8:14 a.m. (resulting in 6 minutes delay of oxygen therapy).