Health inspection·March 15, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 3/15/2024 at 2:46 p.m., with the Director of Nursing (DON), the DON stated it is the nurse's responsibility to provide a dignity bag for all residents with foley catheters for infection control and the residents dignity. During a review of the facility's policy and procedure (P/P) titled TCC/TCU : Residents Rights last revised 12/2023, the P/P indicates , in keeping the mission of this facility, it will be the policy of the facility that all residents have the right to a dignified existence , self- determination, and communication with and access to individuals and services, inside and outside of the facility. The facility must protect and promote the rights of each resident including those with limited cognition and other barriers that limit the exercise of rights. Event ID: Facility ID: 056499 If continuation sheet Page 2 of 12 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 03/15/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 nursing staff failed to ensure residents' activated call light's (requests for assistance) were answered promptly for one of three sampled residents (Resident 255). Residents Affected - Few 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). During a record review of Resident 255's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 3/7/2024, the MDS indicated Resident 255's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The MDS indicated Resident 255 required partial/moderate assistance (helper does less than half of the effort) for toilet hygiene and required supervision on upper body dressing, transferring from sit to lying, chair/bed to bed transfer, and walking. During an observation on 3/12/2024 at 12:06p.m., Resident 255's call light was activated, inside the room, by Resident 255's bed, the call light had been pulled out of the wall, and was on the floor. After three minutes and fifty-six seconds, Resident 255's call light had been turned off by facility staff, and no one had gone to Resident 255's room to see what he needed. During an observation on 3/12/2024 at 12:28 p.m., Resident 255's call light was still on the floor (dislodged from the wall). None of the staff were observed coming to Resident 255's room to check on him and 18 minutes had passed. During a concurrent observation and interview on 3/12/2024 at 12:35p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 had observed Resident 255's call light was on the floor dislodged from the wall. CNA 2 stated if the call light is pulled from the wall, the call light will be activated and lit on the outside of the resident's room. CNA 2 stated call lights should be answered when they are lit, because a resident requires assistance. CNA 2 stated if the call light was not answered, the resident would have to wait, until a staff happen come into the room or if staff is doing their hourly rounding. CNA 2 stated the Certified Nursing Assistants are the ones that answer the call light most of the time, but if the resident required medication, they would inform the nurse. The total time it took for Resident 255's call light to be answered was 27 minutes and 58 seconds by CNA 2. During a review of the facility's P&P titled, TCC/TCU: admission of Patients/Residents revised on 12/2019, the P&P indicated under call light responsibility: it is everyone's responsibility to answer call lights. Caregiver answering call light will call or go back to the room to ensure call light has been answered and resident needs are met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 3 of 12 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 03/15/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 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). Residents Affected - Few 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). During a review of Resident 33's Minimum Data Set (MDS), a standardized assessment and care planning tool dated 2/15/2024, the MDS indicated Resident 33 was cognitively (mental action or process of acquiring knowledge and understanding ability) intact and required supervision for toilet hygiene, transferring from chair/bed to chair, rolling side to side, and is independent (ability to perform activities on their own) for eating, oral hygiene, and dressing the upper body (arms, shoulder). During a review of the Active Orders Quick View (Medication Orders), the Active Orders Quick View indicated Resident 33 has an order for Enoxaparin (Lovenox: medication used to prevent blood clots) 40 milligram (mg: a unit of measure of weight)/0.4 milliliter (ml: a unit of measure of volume) dated 3/1/2024. During a concurrent observation and interview on 3/15/2024 at 8:20 a.m., with Registered Nurse 8 (RN) 8, RN 8 was preparing to administer the Lovenox 40mg and was observed tapping the plunger of the syringe to 'clear the air bubbles' .When RN 8 pushed the syringe plunger, it forced the medication to shoot up from the tip of the needle to an approximate height of six inches into the air. During an interview on 3/15/2024 at 8:34 a.m., with RN 8, RN 8 stated the process of administering Lovenox is to clear the air bubble. RN 8 stated this was a standard practice for her but did not know what the standard of practice for the facility is. RN 8 reiterated that prior to administering Lovenox, she clears the air bubbles until she does not see any bubbles. RN 8 stated indicated the resident did not get the full dose of Lovenox as intended. During an interview on 3/15/2024 at 10:43a.m., with Medication Safety Regulatory Pharmacist (MSR PharmD), the MSR PharmD stated for the Lovenox 40mg, none of the medication should be wasted and the whole dose that is in the syringe should be administered. MSR PharmD stated Lovenox 40mg can be administered as it is without having to clear out the air bubble. The MSR PharmD stated the medication would not be as effective if half of the dose of the medication was wasted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 4 of 12 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 03/15/2024 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 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. Residents Affected - Some 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. Findings: a). During a review of Resident 99's admission Record, the admission record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses including clostridium difficile (a bacterium that causes an infection of the longest part of the large intestine). During a review of Resident 99's physician order dated 3/8/2024, the physician's order indicated intravenous antibiotic therapy of vancomycin antibiotic to treat bacterial infections 50 milligrams ([mg] unit of measurement) /milliliter (ml) liquid, 125 mg to be administered every twelve hours, until 3/20/2024. During an observation on 03/12/2024 at 3:20 p.m., Resident 99's hanging intravenous vancomycin antibiotic bag, had no label. b). During a review of Resident 103's admission Record, the admission record indicated Resident 103 was admitted to the facility on [DATE] with diagnoses including skin and soft tissue infection. During a review of Resident 103's physician order dated 3/10/2024, the physician order indicated intravenous antibiotic therapy of nafcillin (an antibiotic) two grams in sodium chloride (solution) 0.9% every six hours (frequency) until 4/13/2024. During an observation on 03/12/2024 at 2:52 p.m., Resident 103's hanging intravenous nafcillin antibiotic bag, had no label. c). During a review of Resident 106's admission Record, the admission record indicated Resident 106 was admitted to the facility on [DATE] with diagnoses including aspiration pneumonia (food or liquid is breathed into the airways or lungs, instead of being swallowed). During a review of Resident 106's physician order dated 3/7/2024, the physician order indicated intravenous antibiotic therapy of metronidazole (drug for the treatment of infections) in saline (solution), 500 mg three times daily (timing) until 3/11/2024. During an observation on 03/12/2024 at 2:55 p.m., Resident 106's hanging metronidazole intravenous antibiotic bag had no label. During an interview on 03/15/2024 at 3:03 p.m., Registered Nurse (RN) 4 stated that IV medications must be labeled and dated properly when administering to resident because of the possibility of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 5 of 12 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 03/15/2024 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 - Some medication errors and the potential that an IV medication administered belonged to a different resident. RN 4 also stated, it can lead to adverse reactions and even death. During an interview on 03/15/2024 at 3:23 p.m., RN 1 stated that it was a very bad practice not to date and label IV antibiotic administration properly as the medication could potentially be given to the wrong resident which could lead to anaphylactic shock, adverse reaction or even death. During a review of the P&P titled, IV bag Preparation, dated 8/21/2023, the P&P indicated, the IV bag must be labeled with the patient's name and identification number, date and time, the bag number (if applicable), the ordered rate and duration of infusion, and initials. The P&P also indicated to label the IV tubing, IV route at the proximal and distal ends to avoid misconnections to a different route or entry into the body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 6 of 12 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 03/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. Findings: During a concurrent facility kitchen tour observation and interview on 03/12/2024 at 8:33 a.m., there was an opened container of carrots and bread rolls that were unlabeled and undated, and containers of expired cooked chicken meat and beef meat inside the freezer. The kitchen operational manager stated that all expired cooked meat products must be discarded and must not be found in the freezer. Based 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. Findings: During a concurrent facility kitchen tour observation and interview on 03/12/2024 at 8:33 a.m., there was an opened container of carrots and bread rolls that were unlabeled and undated, and containers of expired cooked chicken meat and beef meat inside the freezer. The kitchen operational manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 7 of 12 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 03/15/2024 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 0812 stated that all expired cooked meat products must be discarded and must not be found in the freezer. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 03/12/2024 at 8:42 a.m., there was a scooper in the panko (breadcrumbs or bread flour) container, a scooper inside the long grain rice container, a scooper on top of the parboiled rice container. The kitchen operational manager stated the scooper should not be on top of the breadcrumbs, long grain rice and parboiled rice because it is an infection control issue and could cause cross contamination problem that can lead to foodborne illness. Residents Affected - Many During a tray line (a process of preparing and setting food for the residents' meals in the facility) observation on 03/13/2024 at 10:45 a.m., [NAME] 1 was only wearing a baseball cap and did not wear a hair net. During a tray line observation on 03/13/2024 at 11:07 a.m., the executive chief handed food to [NAME] 1 without wearing gloves. During a tray line observation on 03/13/2024 at 11:12 a.m., dietary aide 3 came to the tray line and started handling the food and transferring it to the food cart without wearing gloves. During a tray line observation on 03/13/2024 at 11:20 a.m., [NAME] 2 repeatedly touched different trays and residents' meal plates without wearing gloves. During a concurrent observation and interview with the kitchen operational manager on 03/13/2024 at 11:25 a.m., a clean paper towel wiped along the inside lining of the ice maker machine resulted in visible black substance on the dirty paper towel. The kitchen operational manager confirmed it the findings. During an interview on 03/14/2024 at 10:13 a.m., the executive chief stated that any staff handling food and transferring food to any other staff without gloves can potentially touch and cross contaminate the foods, and that it was a bad practice. During an interview on 03/14/2024 at 10:15 a.m., [NAME] 2 stated that any kitchen staff handling foods must always wear gloves to prevent contamination. During an interview on 03/14/2024 at 10:20 a.m., the kitchen operational manager stated the ice maker machine must be checked every day to make sure it is clean and free of dirt to prevent from contamination and infection issues. During an interview on 03/14/2024 at 10:25 a.m., [NAME] 1 stated that hair nets must be worn during food preparation to prevent cross contamination. During a review of facility's policy and procedure titled Food Preparation & Distribution revised 12/2020 indicated: To ensure the safe, sanitary, and timely provision of food service to patients. All prepared perishable foods and custard shall be covered, labeled, and dated with a three-day expiration date to be discarded on the day of expiration. During a review of facility's policy and procedure titled Personal Appearance Standards & Uniform Policy revised 12/2020 indicated: Gloves or tongs to be used for handling food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 8 of 12 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 03/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 03/12/2024 at 8:42 a.m., there was a scooper in the panko (breadcrumbs or bread flour) container, a scooper inside the long grain rice container, a scooper on top of the parboiled rice container. The kitchen operational manager stated the scooper should not be on top of the breadcrumbs, long grain rice and parboiled rice because it is an infection control issue and could cause cross contamination problem that can lead to foodborne illness. Residents Affected - Many During a tray line (a process of preparing and setting food for the residents' meals in the facility) observation on 03/13/2024 at 10:45 a.m., [NAME] 1 was only wearing a baseball cap and did not wear a hair net. During a tray line observation on 03/13/2024 at 11:07 a.m., the executive chief handed food to [NAME] 1 without wearing gloves. During a tray line observation on 03/13/2024 at 11:12 a.m., dietary aide 3 came to the tray line and started handling the food and transferring it to the food cart without wearing gloves. During a tray line observation on 03/13/2024 at 11:20 a.m., [NAME] 2 repeatedly touched different trays and residents' meal plates without wearing gloves. During a concurrent observation and interview with the kitchen operational manager on 03/13/2024 at 11:25 a.m., a clean paper towel wiped along the inside lining of the ice maker machine resulted in visible black substance on the dirty paper towel. The kitchen operational manager confirmed it the findings. During an interview on 03/14/2024 at 10:13 a.m., the executive chief stated that any staff handling food and transferring food to any other staff without gloves can potentially touch and cross contaminate the foods, and that it was a bad practice. During an interview on 03/14/2024 at 10:15 a.m., [NAME] 2 stated that any kitchen staff handling foods must always wear gloves to prevent contamination. During an interview on 03/14/2024 at 10:20 a.m., the kitchen operational manager stated the ice maker machine must be checked every day to make sure it is clean and free of dirt to prevent from contamination and infection issues. During an interview on 03/14/2024 at 10:25 a.m., [NAME] 1 stated that hair nets must be worn during food preparation to prevent cross contamination. During a review of facility's policy and procedure titled Food Preparation & Distribution revised 12/2020 indicated: To ensure the safe, sanitary, and timely provision of food service to patients. All prepared perishable foods and custard shall be covered, labeled, and dated with a three-day expiration date to be discarded on the day of expiration. During a review of facility's policy and procedure titled Personal Appearance Standards & Uniform Policy revised 12/2020 indicated: Gloves or tongs to be used for handling food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 9 of 12 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 03/15/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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): Residents Affected - Some 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. Findings: a. During a review of Resident 198's admission record (face sheet), the face sheet indicated Resident 198 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (a condition in which the heart doesn't pump blood as well as it should ), peripheral artery disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and enterococcal bacteremia ( an infection that spreads through the blood stream ). During a review of Resident 198 's history and physical (H&P) report dated 2/ 5 /2024, the H&P indicated resident 198 had the capacity to understand and make decisions. During a review of Resident 198 's Interdisciplinary Team Conference (IDT - Resident's health care team consisting of various specialties) notes, the notes indicated Resident 198 was admitted with a PICC line. During a concurrent observation and interview in Resident 198's room on 3/12/24 at 2:23 p.m., Resident 198 stated she had had the PICC line since she was admitted to the facility on [DATE] (8th day since admission). During a concurrent observation and interview on 3/12/2024 at 2:30 p.m., with Registered Nurse (RN) 1, RN 1 verified the last date of cleaning for the left arm PICC line was 2/24/2024. RN 1 stated that facility staff are to clean the PICC line, sign the dressing, and date it every seven days. RN1 stated the importance of cleaning a PICC line is to prevent the resident from getting infections. During an interview on 3/15/2024 at 9:46 a.m., with the Nurse Manager (NM), the NM stated the facilities protocol is PICC line dressings are to be changed every seven days to prevent line infection. NM stated even if the dressing looks clean you still must clean the site regardless. During a review of the facility's policy and procedure (P/P) titled Comprehensive Vascular Access Management Revised 5/2023, the P/P indicates site care, including skin asepsis and dressing changes, are performed at every seven (7) days and as needed when the dressing integrity is compromised (e.g., damped , loosened or visibly soiled); if moisture , drainage, or blood are present under the dressing; or for further assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 10 of 12 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 03/15/2024 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 Level of Harm - Minimal harm or potential for actual harm b. During a review of Resident 11's untitled admission note dated 2/18/2024, the note indicated Resident 11 was admitted on [DATE] with diagnoses including graves' disease (autoimmune disorder [immune system attacks the healthy cells of your organs and tissues by mistake] that can cause hyperthyroidism, or overactive thyroid (hormone)), dysphagia (difficulty swallowing), hypertension (high blood pressure), and gastrostomy (g-tube: creation of an artificial opening into the stomach for nutritional support). Residents Affected - Some During a record review of Resident 11's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 2/23/2024, the MDS indicated Resident 11's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The MDS indicated Resident 11 was dependent on toileting, eating, lower body dressing, changing positions (sit to lying, sit to stand) and required partial/moderate assistance for oral hygiene and upper body dressing (arms, shoulders). During an observation on 3/14/2024 at 9:39 a.m., with Registered Nurse (RN) 7, RN 7 had four medications that were to be administered to Resident 11 through the g-tube, one medication patch to be applied on the back, and one subcutaneous injection (medications administered between skin and muscle) to the stomach. From the moment RN 7 performed hand hygiene and wore gloves upon entering Resident 11's room, RN 7 was noted scanning Resident 11's wrist band, the medications that were to be administered, and was actively documenting on the computer with the same gloves. RN 7 proceeded to administer the four medications through the g-tube, placed the Lidocaine (medication to help reduce itching and pain) five (5) percent (%) patch on Resident 11's back, and prepared the Heparin (medication to help prevent harmful clots from forming in blood vessels) 5,000 units/milliliter (ml a unit of measure of volume) injection that was to be administered subcutaneously. RN 7 disposed the needle and medication cups after administering all six medications, removed her gloves. RN7 then, without performing hand hygiene wore a new set of gloves, and wiped down (sanitized) the computer station, keyboard, and mouse. With the same gloves, RN 7 got another wipe and wiped down the blood pressure machine so that it can be used for the next resident. During an interview on 3/14/2024 at 10:25 a.m., with RN 7, RN 7 stated hand hygiene should be performed before entering the room, in between touching one's surroundings, taking care of other residents, and before leaving the room. RN 7 stated every time equipment (ex: blood pressure machine) is used on a resident, it should be cleaned right after, and prior to using the device for the next resident. RN 7 stated when she received the blood pressure machine she had assumed it was clean. RN 7 stated since everyone uses the equipment for other Residents, they have the responsibility to clean and disinfect the equipment and cannot assume that it was cleaned prior to using the equipment. RN 7 stated if you are not sure whether the equipment was cleaned, it should be cleaned prior to use, to prevent infections. RN 7 stated hand hygiene is done to prevent infection and if not done properly, it could spread infections to the residents. c. During a review of Resident 17's untitled admission note, dated 2/1/2024, the note indicated Resident 17 was admitted on [DATE] with diagnosis including diabetes (irregular management of blood sugar in blood), stroke (occurs when something blocks the blood supply to part of the brain), and history of fall with right shoulder pain. During a record review of Resident 17's MDS dated [DATE], the MDS indicated Resident 17's cognitive skills were intact. The MDS indicated Resident 17 is dependent on showering and required partial/moderate assistance for all other activities of daily living (ADLs). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 11 of 12 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 03/15/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 3/14/2024 at 8:41a.m., with Registered Nurse (RN) 6, RN 6 was observed performing hand hygiene and applying gloves when entering Resident 17's room, RN 6 checked the resident's identity and started scanning each medication and signed off each medication on the computer for nine medications that were to be administered. RN 6 proceeded to give five medications that were given by mouth, three Lidocaine (Lidoderm: help reduce itching and pain) 5% patches that were applied to the right shoulder, right knee, left knee, and Heparin (help prevent harmful clots from forming in blood vessels) 5,000 units/mL injection that was given on the left upper arm. LVN 6 did not perform hand hygiene nor change gloves throughout the administration and documentation of administration for all nine medications. During an interview on 3/14/2024 at 9:06 a.m., with RN 6, RN 6 stated hand hygiene is performed before coming into contact with a resident, before and after changing gloves, and before leaving the room. RN 6 stated he should have done hand hygiene after administrating each Lidocaine 5% patch prior to giving the Heparin injection. RN 6 stated hand hygiene should be done when coming in contact with skin to prevent infections. RN 6 stated residents may not manifest any symptoms at the moment but still be infected, and he wants to avoid cross contamination and infection since he sees multiple residents. RN 6 stated he should have done hand hygiene and put new gloves on but did not and said he forgot. d. During a review of Resident 201's untitled admission note dated 3/10/2024, the note indicated Resident 201 was admitted on [DATE] with diagnoses including chronic kidney disease (CKD: damaged kidneys that cannot filter blood normally), coronary artery disease (CAD: narrowing and limiting blood flow to the heart), diabetes (irregular management of blood sugar in blood), dyslipidemia (imbalance of fats in the blood), esophageal (muscular tube through which food passes from the throat to the stomach) and gastric ulcer (open sores that develop on the lining of the stomach), and mild hypertension (high blood pressure). During an observation on 3/15/2024 at 10:59 a.m., with Registered Nurse (RN) 1, RN 1 was preparing to administer Heparin (help prevent harmful clots from forming in blood vessels) 5,000 units/mL injection to Resident 201's right lower stomach region. RN 1 administered the medication, disposed of the needle, and signed off on the computer that the medication as given. With the same gloves that was used to administer Heparin, RN 1 got a sanitizing wipe and wiped down the computer and computer mouse. During a review of the facility's P&P titled, Hand Hygiene Policy revised on 9/2019, the P&P indicated compliance with the proper hand hygiene procedure before and after patient contact is an expectation of all healthcare disciplines. Gloves are a protective barrier for the healthcare worker and patients according to Standard Precautions. Gloves are removed when the need for protection no longer exists, and hand hygiene should be practiced immediately after removal of gloves. Hand hygiene will be performed before or after the following activities: before putting on gloves, after taking off gloves, and if moving between contaminated body sites to another body site during care of the same patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056499 If continuation sheet Page 12 of 12