Providence Little Comp of Mary Subacute Care Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents received timely and appropriate Activities of Daily Living (ADL-activities such as bathing, dressing and toileting a person performs daily) care for three of six sampled residents (Resident 42, Resident 51 and Resident 72). The facility failed to:1. Provide incontinent care to Resident 51 and Resident 72 in a timely manner and not leave the residents with soiled incontinence briefs (absorbent, disposable underwear with fastening tabs on both sides) for an extended time.2. Suction (a procedure that is done to help keep a resident 's airway open and free of mucus) Resident 42 's mouth and right nostril who required suctioning to keep airway (the path that air and oxygen to get in and out of the body) clear from secretions (phlegm and saliva). [...]

Inspectors wroteBased on observation and interview the facility failed to provide a safe and sanitary environment in the kitchen for all residents by failing to:a. Ensure cooking oil, powdered brown gravy, cream of wheat, pancake mix and corn starch had open dates.b. Ensure disposable food containers were stored in a sanitary manner.c. Ensure the utility carts in the clean area were free from crumbs, dried food particles and grime (dirt).d. Ensure open aluminum cans were not stored at the workstation. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).

Inspectors wroteBased on observation and interview, the facility failed to ensure the trash receptable was covered, not overflowing with trash and disposed of properly outside the kitchen. This failure had the potential to attract pest/rodents, pose health risk and cause infection control violations.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 20 sampled residents (Resident 105) was provided with an adaptive call light (specialized device for patients with limited mobility) upon admission. This failure put Resident 105's at risk for falls, delay of care, and emotional neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10) had a Level 2 Preadmission Screening and Resident Review (PASARR-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 done when diagnosed with a mental illness prior to admission. This failure had the potential to result in Resident 10 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized and person-centered care plan for two of six residents (Resident 8 and Resident 15) by failing to:a. Develop a new care plan when Resident 8 rash reoccurred.b. Implement the care plan for monitoring Resident 15's inappropriate sexual behavior and providing a psychiatric (relating to mental illness and its treatment) consult to assess Resident 15's behavior. These failures had the potential to put Resident 8 and Resident 15 at risk not to receive the necessary care and services to meet their needs which could compromise Resident 8 and Resident 15 physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 8) was seen by a Dermatologist (doctor who specializes in skin disorders) for an unresolved whole-body rash that started on 7/18/2025. This failure caused Resident 8 to suffer with discomfort and itching and had the potential for infection, sleep disruption and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 15) with behavioral problems was adequately monitored and received the necessary care and services by failing to:Monitor Resident 15's inappropriate sexual behavior towards female and implement plan of care. Provide psychiatric (relating to mental illness and its treatment) care to evaluate and assess Resident 15's inappropriate sexual behavior. This failure placed Resident 15 at risk with a delay in psychosocial (having to do with the mental, emotional, and spiritual aspects of a person's life) needs/care which had the potential for worsening behavior that could pose a danger to other residents.

Inspectors wroteBased on observation, interview and review, the facility failed to observe infection control practices for one of six sampled residents (Resident 34) by failing to:1. Ensure the linen hamper lid was closed and not overflowing with dirty gowns in Resident 34's bathroom. This failure had the potential to cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread of infection among the residents, staff and visitors in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two residents (Resident 22) and resident representatives were provided education regarding the risks and benefits of refusing influenza (flu - a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) vaccination. This failure had the potential to result in the resident or resident representative making uninformed decisions regarding refusal of influenza vaccine, increasing the risk for vaccine-preventable illness, complications, hospitalization, and transmission of infection within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices when: 1. Certified Nursing Assistant 1 (CNA 1) provided care to Patient 2 then proceeded to Patient 1s bedside without changing CNA 1s personal protective equipment (PPE) gown prior to initiating care for Patient 1. 2. CNA 2 placed clean linen intended for Patient 1 on top of a used soiled linen cart and proceeded to Patient 1s bedside to initiate care. These deficient practices had the potential to cause cross-contamination (the unintentional physical movement or transfer of harmful bacteria from one person, object, or place to another) of infectious pathogens (bacteria and microorganisms) from patient to patient and/or within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Several food items were not dated for thaw date in the walk-in refrigerator. One box of pepperoni was stored uncovered in the walk-in freezer. One medium container of black beans with expire date of 12/1/2024, one large container of blueberry sauce for toppings and one large container of cooked apple with an expire date of 11/30/2024 exceeding storage period for the food were stored in the reach in refrigerator. Two boxes of (baked pastry) and one package of sliced ready to eat turkey deli meat were stored on the shelf next to raw shelled eggs. One box of raw chicken thighs thawing on the shelf next to raw ground beef. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas located in the loading and food delivery area behind the kitchen were maintained in a sanitary manner. One of six garbage dumpsters had the lid open, the dumpster was uncovered and overfilled with cardboard, and trash. There were disposable gloves, plastic, paper, and food on the ground surrounding the trash dumpsters. The trash was in the loading and food delivery area next to the kitchen back door. This deficient practice had the potential for harborage and feeding of pests, which may be attracted into the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to the California Department of Public Health (CDPH) for one of two sampled residents (Resident 41) when Resident 41 developed a blood (a fluid-filled sac in the outer layer of skin) blister on the right big toe of the right foot. This failure had the potential to result into a delayed investigation to rule out abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 84 and Resident 96) were free of unnecessary psychotropic (any drug that affects the brain activities associated with mental processes and behavior) medications by failing to: 1. Ensure Resident 84 and Resident 96 were provided with non-pharmacological interventions (intervention that does not primarily use medicine before administering a prn (as needed) psychotropic medication. 2. Ensure prn psychotropic medication use had not exceeded 14 days. These failures placed Resident 84 and Resident 96 at risk for adverse consequences (unintended, harmful events attributed to the use of medication) due to unnecessary prolonged use of psychotropic medication.

Inspectors wroteBased on observation interview and record review the facility failed to ensure one of 22 sampled residents (Resident 46's food and cultural preferences were honored. This failure resulted in weight loss due to inadequate consumed calories for residents who did not receive the food items of their choices and preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for three of 10 residents (Resident 29, 62, and 86) by failing to: 1. Ensure Resident 29's water bag was labeled and dated. 2. Ensure Resident 62's tube feeding bottle was labeled and dated. 3. Ensure Resident 86's tube feeding bottle was dated. These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Residents 29, 62, and 86.

Inspectors wroteBased on interview and record review, the facility failed to address and monitor the use of antibiotic on two of five sampled residents (Resident 41 and Resident 98) when residents' conditions or symptoms did not meet McGeer criteria(a set of criteria used in long term care facilities to determine if signs and symptoms constitute a true infection). This failure had the potential to result in Resident 41 and Resident 98 developing resistance (antibiotic will not be effective to treat infection) from unnecessary or inappropriate use of antibiotic.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure six of seven sampled residents (Residents 39, 45, 20, 11, 68 and 27) were free of unnecessary physical restraints (devices that limit a patient's movement) by failing to: 1. Ensure six of seven residents (Residents 39, 45, 20, 11, 68 and 27) were free from physical restraints. 2. Follow the Physical Restraint Elimination Assessment (assessment used by the facility for restrained residents to determine whether they are candidates for restraint reduction, score of 0-20 is a priority candidate, 21-35 good candidate, and 35 and above is a poor candidate) for Residents 39, 45, 20, 11, 68 and 27, monthly to assess for the need of physical restraint continued used. 3. [...]

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 multiple canned foods, meat products, and vegetables with opened date and received date. 2. Ensure [NAME] 2 did not repeatedly placed the plastic serving spoon in the soiled area and used it to transfer food to the plate. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident Minimum Data Set ([MDS] a resident standardized assessment and care screening tool) assessment was transmitted within 14 days after completion for one of five sampled residents (Resident 3). This deficient practice resulted in late data transmitted to Centers for Medicare and Medicaid Services (CMS) regarding Resident's 3 medical status while in the facility.

Inspectors wroteBased on observation, interview and record review, the licensed nurses failed to follow the facility policy and procedure (P&P) for initiation and maintenance of intravenous therapy ([IV] a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) for three of three residents (Residents 92, 65 and 49) as evidenced by: 1. Failing to label and date a peripheral intravenous catheter ([PIV] a short catheter inserted through a peripheral vein for the administration of solution or medication) site for Resident 65. 2. Failing to label and date extension tubing (tubing that is connected to the intravenous catheter upon insertion) to administer solution or medication directly into the resident vein. 3. Failing to obtain a physician order (PO) to insert a PIV in Residents 49 left foot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for six of seven sampled residents (Resident 39,45,20,11,68 and 27), as indicated in the facility's policy and procedure by failing to: 1. Assess and complete the Bed Rail Use and Entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) Risk Assessment for Resident 39,45,20,11,68 and 27 per facility's policy and procedure (P&P). 2. Implement a care plan for the use of bed rails. These deficient practices had the potential to physical harm from possible entrapment (when a person is trapped by the bed rail in a position they cannot move from) from the use of bed rails for Resident 39,45,20,11,68 and 27. During an observation on 12/11/2023 at 11:55 a.m. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to: 1. Reach QAPI goal of 100% for Restraint Reason Justification for the third quarter 2023 (July, August, and September). 2. Reach QAPI goal of 100% for Restraint Assessment for the third quarter 2023 (July, August, and September). 3. Reach QAPI goal of 100% for Restraint Documentation for the third quarter 2023 (July, August, and September). 4. Reach QAPI goal of 100% for Restraint Documentation for the third quarter 2023 (July, August, and September). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures by failing to: 1. Practice hand hygiene after removal and before putting on a new pair of gloves during medication pass observation. 2. Clean blood pressure machine ( BP- measurement of the force of blood that is flowing through the blood vessels) after using on Resident 30. 3. Dispose used gown to the designated trash bin inside the resident's room. 4. Ensure doffed off (to remove or take off) used personal protective equipment ([PPE] protective clothing, garments or equipment designed to protect the wearer or the resident from infections) such as gloves and gown while walking in the hallway. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure call light was within reach on one of six sampled residents ( Resident 75). This failure had the potential to result in a delay of treatment for Resident 75 pain on the right side of her body and inability for Resident 75 to obtain necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six sample residents (Resident 11 and Resident 20) received the care and services necessary to prevent complications while managing their gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) while providing care by failing to: 1. Ensure Resident 11's G- tube was assessed for feeding tolerance during medication pass observation. 2. Ensure Resident 20's tube feeding ( liquid form of food that is delivered through the body through a flexible tube called gastrostomy tube) was labeled and dated appropriately according to the facility's Policy & Procedure (P&P). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 11) had an adequate amount of oxygen in the portable oxygen tank ( light, small tank that allow resident to receive supplemental oxygen ) while attending an activity and while in the patio. This failure had the potential to affect Resident 11's breathing and could cause desaturation (low blood oxygen concentration) from not receiving adequate amount of oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 49) received care and services for the provision of parenteral fluids (medication administered in a manner other than the digestive system) consistent with professional standards of practice by failing to : 1. Ensure staff followed the facility's policy and procedure (P&P), titled, Comprehensive Vascular Access Management prior to the insertion of a peripheral intravenous catheter ([IV] a line inserted into the skin used to give fluids and medications) into Resident 49's left foot. 2. Ensure nursing staff assessed and monitored Resident 49's IV site appropriately during the administration of medication through his left foot IV. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure it was free of medication error rate of five percent or greater during the medication pass observation by failing to administer two medications on one of four sampled residents (Resident 30) as ordered by the physician. 2. Check or verify name and date of birth of Resident 30's with his identification band ([ID] an armband that ensures accurate identification and includes the name and date of birth of a resident) before administering medications. These failures resulted to a medication error of 8 percent (%) out of 25 opportunities and had the potential to give medications to a wrong resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of the two sampled patients (Patient 1), Patient 1's medications was administered by a licensed personnel or the patient's family member who had received educational training on the administration of Venelex ointment (a topical medication use in the management of wound) and Triad cream (a topical medication use in the management of wound) in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in medication error and for Patient 1's wound to have an ineffective treatment and delayed healing of the wound.