Health inspection·September 22, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based 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.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. Findings: During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 6/23/25, Resident 1's H&P indicated that Resident 1 had a past medical history of hypertension (HTN, high blood pressure), hyperlipidemia (high levels of fat in the blood), cardiomyopathy (a disease causing the heart muscle to become thick stiff, or enlarged, making it harder for the heart to pump blood to the body), and chronic back pain (persistent pain, stiffness, or discomfort in the back that lasts for more than three month) after a fall. Resident 1 was admitted for further physical therapy and rehab.During a concurrent interview and record review on 9/22/25 at 2:43 p.m. with the Nursing Director, the list of residents with room changes for the month of August and September was reviewed. The list did not indicate Resident 1 had a room change. ND stated that Resident 1 was moved on 6/26/25 from room A to room B to accommodate a male resident. Resident 1 was assigned to a room with another female resident. On 7/21/25, Resident 1 requested to be moved from room B to room D due to a confused resident across from room B. On 8/28/25, Resident 1 was moved to room C to accommodate a Federal Correctional Institute (FCI, inmate) resident that required continuous observation by two guards. On 8/29/25, Resident 1 requested to be moved from room C to room A to be closer to a patio exit door for easier access during smoke breaks (outdoor time accompanied by staff to allow smoking residents personal time for cigarettes). On 9/5/25, Resident 1 requested to move from room A and was placed in room E with two other female residents. ND stated that Resident 1 did not like room E and requested to return to room A.During a concurrent interview and record review on 9/22/25 at 3:27 p.m., the facility's Room Change Notification forms were reviewed. There were no forms for Resident 1's room changes. ND stated Resident 1 did not sign the room change notification form and that this was an identified gap which is being corrected. ND further stated this deviation in practice has been identified with immediate corrective actions taken.During an interview on 9/22/25 at 3:15 p.m. with Charge Nurse (CN) 1, CN 1 stated, when a room change is needed, if the resident is alert and oriented, the resident is asked permission for the room change with the reason for the change explained. If the resident is not Page 1 of 2 056499 056499 09/22/2025 Providence Little CO of Mary Transitional Care Ctr 4320 Maricopa Street Torrance, CA 90503

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alert, the family/responsible party is notified. If the room change is refused by the resident/family/responsible party, the room change is stopped. Most room change notifications are documented in the resident's digital chart. Each resident's room have signage notifying the residents that their room is not permanent during their stay at the facility, per CN 1. During an interview on 9/22/25 at 3:31 p.m. with CN 2, CN 2 stated, if a room change is required, the resident and/or family are alerted for consent. If the resident/family agrees to the change, the room change notification form is completed. If the resident/family refuse, the room change notification form is still completed, indicating the resident's/family's refusal, but no room change would take place as the resident's/family's decision is honored. Changing a resident's room against their will could lead to the resident's distrust of the facility and a violation of the resident's rights. During an interview on 9/22/25 at 3:46 p.m. with the Nursing Director, the ND stated all resident room changes followed a structured process. The residents are asked for their consent, with their preferences carefully considered. The families/responsible parties are informed of the planned room change and the reason for the change. A Room Change Notification form is completed, and written notice is provided to the resident and/or family member/responsible party. This process ensured compliance with regulations while protecting residents' rights, dignity, and comfort. Unauthorized room changes may result in a resident's physical decline or cause emotional distress due to the lack of control over their own decisions and unhappiness with their living arrangements, which may contribute to the resident giving up. In this case, several room changes were made; however, the Room Change Notification form was not completed and signed by Resident 1, which the facility recognized as a deviation from the standard process. During a review of the facility's policy and procedure (P&P), titled Transitional Care Center: Notification of Change in Resident Status, effective 07/2025, page one of three, the Policy section indicated, In keeping with the mission and core values of Providence, it will be the policy of the facility to assure that the physician and family member or legal authorized representative are promptly notified in the event of a change in the Resident's status. The Procedure section indicated: The facility will also promptly notify the resident or resident's legal representative designated family member/next of kin when there is: a. A change in room or room assignment b. A change in residents' rights under Federal or State law. During a review of the facility's P&P, titled Transitional Care Center: Transfer, Discharge, Bed Hold Notification and Requirements, effective 09/2024, the Procedure/General Instructions section indicated, Except in an emergency, residents will not transfer to another room against his or her wishes, unless given prior reasonable written notice. 056499 Page 2 of 2