Health inspection·November 3, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based 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. Findings: During a review of Patient 1's PCP (primary care provider) Meeting Progress Note, dated 10/19/2023, the progress note indicated Patient 1's assessment and plan included chronic respiratory failure (a condition where there's not enough oxygen in the body). In addition, the note indicated Patient 1 had a moisture-associated dermatitis to the buttocks and the plan was to treat with topical care and nutritional support. During a review of Patient 1's wound care orders titled Wound Care Right Buttock Skin Maintenance, dated 10/20/2023, it was indicated, Gently cleanse buttocks with soap and water or cleansing wipes. Apply Triad to the area daily and as needed for skin maintenance. During an interview on 10/31/2023 at 2:30 p.m., with the Wound Care Nurse (WCN) 1, WCN 1 stated, Patient 1's family member had been applying the Triad and Venelex ointment to Patient 1's wound on the buttocks. In the same interview, WCN 1 stated when the patient or the patient's family member wanted to do self-administration of the medication, they must go through a medication self-administration training with the educator, then the patient or the family member would sign a form indicating the patient or the patient's family member had completed the training. The self-administration medication form would be in the patient's record. Furthermore, WCN 1 stated she cannot locate the self-administration medication form in Patient 1's chart. WCN 1 stated she cannot confirm that Patient 1's family member had the training on self-administration of Triad and Venelex medications to Patient 1. During a review of the facility's (P&P) titled Interdisciplinary Education/Teaching Record of Resident/Family, dated September 2023, the P&P indicated the following: to ensure education and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555848 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 555848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732 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)