Health inspection·May 24, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm and history of UTI. The DON stated a care plan should have been done to focus on the concern for indwelling catheter with follow up with the physician for adequate urine output. b. On 5/20/19, at 12:50 a.m., during the initial tour of the facility, Resident 91 was observed lying in bed and receiving oxygen at 2.0 liters per minute through a nasal cannula (NC). Residents Affected - Few According to the admission records Resident 91 was admitted on [DATE], with diagnoses that included cardiovascular accident (stroke). A review of Resident 91's clinical record revealed the facility did not develop a specific comprehensive care plan for the use of oxygen therapy to maintain oxygen saturation between 94 to 98 percent as ordered by the physician. On 5/24/19, at 10:15 a.m., during an interview, the DON was asked if the facility develop a specific care plan for the resident receiving oxygen. The DON stated no specific care plan was developed but a discharge care plan and cardiac output care plan was done. According to the State Operation Manual (SOM) Care Plan, the facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The care planning drives the type of care and services that a resident received (SOM revised November 22, 2017, P.207). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Little CO of Mary Transitional Care Ctr 4320 Maricopa Street Torrance, CA 90503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff administered the total parental nutrition ([TPN] a method of feeding that bypasses the gastrointestinal tract; fluids are given into a vein to provide most of the nutrients the body needs; the method is used when a person can not or should not receive feedings or fluids by mouth) through the peripherally inserted central catheter ([PICC] a thin, soft, long tube that is inserted into a vein on arm, leg or neck, with the tip of the catheter positioned in a large vein that carries blood into the heart), when used for long-term intravenous ([IV] into a vein) administration of antibiotics, nutrition or medications, and for blood draws, and not through the regular peripheral IV access line for one of 17 sampled residents (33). Residents Affected - Few This deficient practice had the potential to cause burning, discoloration to the IV site, and damage Resident 33's veins. Findings: On 05/21/19 at 8:08 a.m., during observation, and interview, Resident 33 was observed with a peripherally inserted central catheter (PICC) line in the left upper arm. Resident 33's PICC line was not connected to any tubing or line and there was no fluids infusing at the time of observation. Concurrently, during the observation, there was TPN infusing at 150 milliliter per hour (ml/hr) in Resident 33's right arm. However, Resident 33's TPN was infusing through a regular IV line, connected to a saline lock (an intravenous catheter that is threaded into a peripheral vein, flushed with saline, and then capped off for later use). During the same time, Registered Nurse (RN 33) was observed to discontinue the TPN from the resident's right arm saline lock. During an interview RN 33 was asked if the TPN was administered through the peripheral saline lock and not the PICC line, RN 33 stated yes. When asked about Resident 33's left arm PICC line, RN 33 stated we do not use that. According to Resident 33's admission record, indicated the resident was admitted to the facility on [DATE], with diagnoses that included gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), and osteoporosis (thinning of the bones). According to Resident 33's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 05/05/19, indicated the resident had no impairment in cognitive skills for daily decision-making, and required limited to extensive assistance from staff for activities of daily living. A review of the active PICC audit report for Resident 33 indicated it was placed in the resident's left upper arm on 05/03/19. The audit report indicated PICC line was for medication/fluid administration. A review of Resident 33's TPN order from the pharmacy, dated 05/20/19 indicated to administer TPN on 05/20/19, to start at 8:00 p.m. A review of Resident 33's physician order indicated to administer TPN through the intravenous central route (PICC), administer over 14 hours, and for TPN to end on 05/21/19 at 10:03 am. A review of the licensed nurses progress notes for Resident 33, dated 05/18/19, indicated Registered Nurse (RN 31) changed the IV site from peripheral IV to the right forearm (RFA) due to single PICC. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Little CO of Mary Transitional Care Ctr 4320 Maricopa Street Torrance, CA 90503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with RN supervisor at 9:30 am, in regards to Resident 33's TPN infusing in to a peripheral line, stated we do not infuse TPN via peripheral line. RN supervisor stated the vein was not able to tolerate TPN, and the facility always used central lines (PICC) line for TPN administration. During interview with RN 33 on 05/23/19 at 9:44 am stated she observed TPN infusing through the right arm peripheral IV line and as an RN she knew TPN should had been infused through the central line. During an interview with the facility's consulting pharmacist on 05/23/19 at 2:26 p.m., stated the registered nurses should check orders before administering any fluids or medications. The pharmacist stated infusing TPN through a peripheral line can cause vein irritation, and cause burning at the site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Little CO of Mary Transitional Care Ctr 4320 Maricopa Street Torrance, CA 90503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the staff did not wear a personal protective equipment (protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection), by wearing a disposable yellow gown outside of a contact isolation room (used for infections, diseases, or germs that are spread by touching the patient or items in the room). Residents Affected - Few This deficient practice placed the resident's, staff, and visitors at for cross contamination. Findings: During an observation of the facility on 05/22/19 at 11:45 a.m., the environmental service (EVS) staff was observed coming outside of a contact isolation room, while still wearing the disposable yellow gown. The gown was exposed to barrels and a mop bucket cart, which was parked outside the isolation room. During an interview with Infection Control Nurse (ICN) on 05/22/19 at 11:47 am, stated EVS staff should not be coming out from the isolation room still wearing the PPE, yellow disposable gown. Concurrently, ICN instructed EVS staff to wipe down barrels, and the mop bucket, to prevent cross contamination throughout the facility. During an interview with EVS staff on 05/22/19 at 11:48 a.m., stated disposable yellow PPE gowns should be worn, the disposed inside the isolation rooms prior to leaving the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 5 of 5