Health inspection·December 14, 2023

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 facility failed to ensure call light was within reach on one of six sampled residents ( Resident 75). Residents Affected - Few 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. Findings: During a review of Resident 75's admission Record (Face Sheet), the Face Sheet indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including sepsis (life threatening complication of an infection), functional quadriplegia ( complete immobility due to severe disability or frailty from other medical condition), amyotrophic lateral sclerosis ( [ALS] nervous disease that affects nerve cells in the brain and spinal cord causing loss of muscle control) diabetes, and acute on chronic respiratory failure ( inability of lungs to meet oxygen needs of the body). During a review of Resident 75's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 9/15/2023, the MDS indicated Resident 75 had an intact cognition (ability to learn, remember, understand, and make decisions) and required two persons assist with bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident 75 was incontinent (having no or insufficient control over defecation) of stool and had an indwelling catheter (flexible tube used to empty the bladder and collect urine in a drainage bag). During a concurrent observation and interview on 12/11/2023, at 1:53 p.m. with Resident 75, observed Resident 75 was lying in bed with a tracheostomy (opening in the windpipe that provides an alternative airway for breathing) connected to a ventilator( machine that provides artificial respiration) and splints ( a strip of rigid material used for supporting and immobilizing) on both hands. Resident 75 used an electronic device (tablet) to communicate during interview. Resident 75 complained of pain on the right side of her body and could not call for help because the call light was not within his reach. Observed an adaptive call light (mechanical pad that had ultra-sensitive touch surfaces that is ideal for patients with limited mobility) on top of the tray basket secured to the wall and located in the head part of the bed. During a concurrent observation and interview on 12/11/2023, at 2 p.m. with Respiratory Therapist (RT) 4, RT 4 stated Resident 75's call light was on top of the basket tray and was not within reach of Resident 75. RT 4 stated call light of Resident 75 should be within reach so she can call for assistance from staff members as need arises. Page 1 of 37 555848 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/11/2023, at 2:10 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 75's call light must have been placed by the radiology personnel who performed a test on Resident 75. CNA 4 stated it was the responsibility of all facility staff to ensure call light was within reach for all residents. During an interview on 12/15/2023, at 10:34 a.m. with CNA 6, CNA 6 stated Resident 75 used an adaptive call light, and placed it next to her face because she was unable to move her hands to use the call light. CNA 6 stated Resident 75 would be upset or frustrated and could have an unrelieved pain because she would not be able to ask for help. During an interview on 12/15/2023, at 10:07 a.m. with Nurse Manager (NM) 2, NM 2 stated call lights should be within easy reach for all residents for safety and ensure their needs were attended. During a review of facility's policy and procedure (P&P) titled Resident Rights revised 9/2022, the P&P indicated the facility should ensure the staff would promptly addresses residents' requests for assistance and it was the responsibility of each staff member to protect and promote each resident rights. 555848 Page 2 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some Based 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. Release physical restraint every two (2) hours for 15 minutes to ensure good blood circulation (the flow of fluid, especially blood) to upper extremities and assess skin integrity (the skin being whole, intact, and undamaged) for Residents 39, 45, 20, 11, 68 and 27. 4. Use least restrictive measures (restraint that allows the most freedom of movement while still protecting the resident) prior to use of physical restraints per facility's policies and procedures (P&P), titled Physical Restraints for Residents 39, 45, 20, 11, 68 and 27. 5. Ensure soft wrist restraints (soft material or fabric fit around the limbs [arm or leg] of an individual to limit movement and to prevent the dislodgment of tubes, lines, and catheters) were applied correctly and secured in proper position to Resident 39 and 20's bed frame per manufacturer guidelines (instructions provided by maker of a product to provide detailed insight into how to equipment should be used). These deficient practices placed Residents' 39, 45, 20, 11, 68 and 27, at risk for impaired blood circulation with possible formation of venous stasis ulcers (medical condition characterized by impaired blood flow in the veins), skin injuries including pressure ulcer (an injury that breaks down the skin and underlying tissue) and psychosocial harm from not being treated with respect and dignity. On 12/12/2023 at 4:57 p.m., the Director of Nursing (DON) and Nurse Manager were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious, injury, harm, impairment, or death to a resident ) was called due to six residents, Residents 39, 11 and 27 on right soft mittens (used to prevent residents from pulling out any essential lines or tubes) and right soft wrist restraints, 20 on left soft mittens and left soft wrist restraints, Resident 45 on bilateral soft mittens and 68 on right soft mitten, failed to follow the Physical Restraint Elimination Assessment for all 6 residents, failed to release physical restraint every two (2) hours for 15 minutes for all six residents, failed to use least restrictive measures prior to use of physical restraints for all six residents and failed to ensure soft wrist restraints were applied correctly for Residents 39 and 20. The facility's DON, and Nurse Manager were notified of the seriousness of the risk of physical restraints. An IJ Removal Plan was requested from the facility's staff. 555848 Page 3 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 12/14/2023 the facility submitted an acceptable IJ Removal Plan. On 12/14/23 at 6:21 p.m., the DON and Core Leader were notified the IJ was removed after on-site validation of the implementation of the IJ Removal Plan via observations, interviews, and record review. The IJ Removal Plan included the following: 1. Facility management rounded on 12/12/2023 on Resident 39, 20,11, and 27 to validate appropriate restraint placement and securement to the bed was in the quick-release manner, per manufacturer's guidelines. 2. Facility management rounded on 12/12/2023 on Resident 45 and 68 to validate appropriate restraint placement. 3. Physician's orders stating needs for physical restraints were reviewed for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23. 4. Nursing assessments on continued need for restraints reviewed for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23. 5. Alternatives for physical restraints were attempted and documented within restraint non-violent flowsheet every shift for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 6. Peripheral, neurovascular (involving both nerves and blood vessels), and skin assessments performed and documented every two hours for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 7. Physical restraints released for 15 min every two hours and documented for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 8. Trial off physical restraints conducted on 12/14/23 from 8:15 am to 8:25 am to evaluate the continued necessity for restraints for Resident 39. Right hand mitten and right soft wrist restraint were removed for Resident 39. Resident 39 failed trial on 12/14/23. 9. Trial off physical restraints conducted on 12/13/23 from 2:00 pm to 2:30 pm to evaluate the continued necessity for restraints for Resident 45. Bilateral soft mittens were removed. Resident 45 tolerated trial off restraints. Trial continues per facility's policy and procedures. 10. Trial off physical restraints conducted on 12/13/23 from 10:30 pm to 10:35 pm to evaluate the continued necessity for restraints for Resident 20. Right hand mitten and right soft wrist restraints were removed for Resident 20. Resident 20 failed trial on 12/13/23. 11. Trial off physical restraints conducted on 12/13/23 from 8:05 pm to 8:15 pm to evaluate the continued necessity for restraints for Resident 11. Right hand mitten and right soft wrist restraints were removed for Resident 11. Resident 11 failed trial on 12/13/23. 12. Trial off physical restraints conducted on 12/13/23 from 8:55 pm to 9:09 pm to evaluate the continued necessity for restraints for Resident 68. Right hand mitten was removed for Resident 68. Resident 68 failed trial on 12/13/23. 13. Trial off physical restraints conducted on 12/13/23 from 7:45 pm to 7:49 pm to evaluate the 555848 Page 4 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some continued necessity for restraints for Resident 27. Right hand mitten and right soft wrist restraints were removed for Resident 27. Resident 27 failed trial on 12/13/23. 14. Least restrictive restraint attempted on 12/14/23 at 12:15 pm, right soft wrist restraint removed. Resident 39 tolerating will continue to monitor. 15. Least restrictive restraint attempted for Resident 20 on 12/14/23 at 12:45 pm, right soft wrist restraint removed. Resident 20 failed. 16. Least restrictive restraint attempted for Resident 27 on 12/14/23 at 12:15 pm, right soft wrist restraint removed. Resident 27 failed. 17. Reviewed side rails assessment form for Resident 39, 45,20,27,11 and 68 on 12/14/2023, which included recommendations to use bilateral padded upper and lower side rails. 18. Assess resident for risk for entrapment and document by 12/15/23. Findings: 1.During an observation on 12/11/2023 at 11:55 a.m. at Resident 39's bedside, Resident 39 was observed non-verbal with a soft wrist restraint on the right wrist, a soft mitten restraint on the right hand and all four siderails up on the bed. During a review of Resident 39's admission Record (Face Sheet) the Face Sheet indicated Resident 39 was admitted on [DATE] with diagnoses including respiratory failure (a condition in which your blood doesn't have enough oxygen), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck) and cerebral vascular accident (CVA[ an interruption in the flow of blood to cells in the brain]) with left arm weakness. During a review of Resident 39's Minimum Assessment Set (MDS - a standardized assessment and care screening tool) dated 11/10/2023, the MDS indicated Resident 39 had severe cognitive (ability to learn, remember, understand, and make decisions) and memory impairment for daily decision making. Resident 39 had impairment (weakness) on both arms and was dependent for all activities of daily living (ADLconsist of eating, dressing/grooming, bathing/personal hygiene, mobility (ambulation and transfer), elimination [toileting]). The MDS indicated Resident 39 used one limb (right arm) physical restraints on the right upper extremity. During an observation on 12/11/2023 at 10:24 a.m. at Resident 45's bedside, Resident 45 was observed with bilateral (both) mitten restraints to the hands. During a review of Resident 45's admission Record (Face Sheet) the Face Sheet indicated Resident 45 was admitted on [DATE] with diagnoses including respiratory failure, dementia (a condition characterized by progress loss of intellectual functioning with memory impairment), and status post fall. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severe cognitive impairment for daily decision making. Resident 45 had impairment on both arms and was dependent for all ADL. The MDS indicated Resident 45 had bilateral (both) hand restraints. During a review of Resident 20's admission Record (Face Sheet ), the Face Sheet indicated Resident 555848 Page 5 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Level of Harm - Immediate jeopardy to resident health or safety 20 was admitted on [DATE] and readmitted on [DATE] with diagnoses including deep venous thrombosis (blood clot formed in the deep vein of the body), history of traumatic brain injury (damage to the brain that disrupts normal functioning caused by an outside force, typically such as a violent blow to the head), functional quadriplegia (complete immobility to move due to physical disability or frailty), gastrostomy (opening into the stomach from the abdomen for the introduction of food), presence of tracheostomy, and history of CVA. Residents Affected - Some During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20 had severely impaired cognitive skills and was dependent on staff members with bed mobility, bathing, personal hygiene, dressing and toileting. The MDS indicated Resident 20 was on upper limb restraint. During a review of Resident 20's Physician Order dated 10/19/2023 timed at 11:50 p.m., the Physician Order indicated an order to place left hand soft mitten (used to prevent residents from pulling out any essential lines or tubes) and left soft wrist restraints to prevent from pulling out tubes, release and check for redness, circulation, hydration, nutritional/elimination needs, hygiene, safety every two hours and perform range of motion ([ROM] is the extent of movement of a joint, measured in degrees of a circle) exercises until discontinued. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted on [DATE] with diagnoses including history of hemorrhagic stroke (blood vessels rupture in or near the brain which can cause permanent damage to the brain), tracheostomy, chronic respiratory failure, ileostomy (opening in the abdomen to evacuate stool from the body), anoxic brain injury( blood flow and oxygen to the brain was interrupted which can cause damage to the brain),and dysphagia ( difficulty of swallowing). During a review of Resident 11's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/15/2023, the MDS indicated Resident 11 had severely impaired cognitive skills and was dependent on staff members with bed mobility, transfer from bed to wheelchair, bathing, toileting hygiene and personal hygiene. The MDS indicated Resident 11 had an indwelling catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) and ostomy (creation of an artificial opening in the abdomen to allow for the elimination of body wastes). During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated Resident 68's was admitted on [DATE] with diagnoses including aneurysm (an abnormal bulge or ballooning in the wall of a blood vessel), subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), cerebral edema (swelling of the brain), tracheostomy and gastrostomy. During a review of Resident 68's MDS dated [DATE] indicated Resident 68 had severe cognitive impairment and requires total assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident 68 used limb (right arm) restraint daily. During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted on 8/2014, with diagnoses including traumatic brain injury, epilepsy (seizure disorder sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), dysphagia, respiratory failure tracheostomy and gastrostomy. During a review of Resident 27's History and Physical (H/P), dated 1/3/23, the H/P indicated, Resident 27 did not have the ability to communicate. 555848 Page 6 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During a review of Resident 27's MDS dated [DATE], the MDS indicated, Resident 27 had persistent vegetative state/no discernible consciousness (when a person is awake but is showing no signs of awareness). Resident 27 required extensive assistance (resident total dependent; full staff assistance) with bed mobility and extensive assistance with transferring, dressing, toilet use, personal hygiene and did not utilize a mobility device. The MDS indicated Resident 27 utilized a limb (right arm) restraint daily. 2. During a concurrent interview and record review on 12/12/2023 on 2:15 p.m. with the Nurse Manager (NM) 1, NM 1 stated Resident 39 Physical Restraint Elimination Record assessment score was 26. NM 1 stated a score of 21-35 means Resident 39 was a good candidate to have a trial to see if the restraints can be released. During a review of Resident 20's Physical Restraint Elimination Assessment, the Physical Restraint Elimination assessment indicated Resident 20 was assessed on 10/1/2023, 11/1/2023 and 12/1/2023 with a score of 22 (score of 22 was a good candidate for restraint reduction). During a review of Resident 20's Nurses Progress Notes dated 10/22/2023, at 12:59 p.m., the Nurses Progress Notes indicated the Resident 20 had episodes of pulling essential lines when restraints were released and was not a good candidate for restraints removal. There was no other documentation except for 10/20/2023 and 10/22/2023 regarding weekly assessment of restraint usage for the month of October 2023. During a review of Resident 20's Nursing Progress Notes for the month of November 2023, the Nursing Progress Notes indicated on 11/13/23, 11/19/2023, and 11/28/23 Resident 20 was not a candidate for restraint removal of hand soft mitten and soft wrist restraint due to pulling of essential lines (tracheostomy and gastrostomy tube) when restraints were removed. The Nursing Progress Notes indicated no weekly assessment was done for the week of 10/29/2023 and 11/5/2023. During a review of Resident 20's Nursing Progress Notes for October, November and up to December 11, 2023, the Nursing Progress Notes indicated no trial of restraint removal or least restrictive restraint was attempted and was documented. During a review of Resident 11's Physical Restraint Elimination Assessment, the Physical Restraint Elimination Assessment indicated on 8/1/2023, 9/1/2023, 10/1/2023 and 11/1/2023 Resident 11's score was 24. The Physical Restraint Elimination Assessment indicated a score of 24 was a good candidate for restraint reduction. During a review of Resident 11's Restraints Progress Notes for the month of October 2023, the Restraints Progress Notes indicated weekly assessment for restraint use was performed on 10/1/2023, 10/15/2023, 10/22/2023, and 10/29/2023.The Progress Notes indicated no weekly assessment done for the week of 10/8/2023. During an interview on 12/12/2023, at 2:17 p.m. with Nurse Manager (NM) 1, NM 1 stated Restraints Elimination Assessment was used to determine if a resident (in general) on restraints was a good candidate for reduction or if restraints can be released from restraints. NM 1 stated the low score on the assessment indicates resident (in general) was a good candidate for restraints reduction. NM 1 stated the assessment of restraints were performed weekly by registered nurses' and the licensed nurses must be physically present to release the restraints, check the resident's skin and circulation. NM 1 stated unnecessary restraints could inhibit residents' mobility. 555848 Page 7 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 3. During a review of Resident 39's Physician Order dated 3/9/2022, indicated Resident 39 with right hand soft mitten and release every two hours for blood circulation check, redness, and safety, and to apply a right soft wrist restraint and to release every two hours for blood circulation check, redness, and safety. During a review of Resident 39's Restraint Every Two-Hour Monitoring record (documentation log used when residents are in restraints) dated 12/9/2023 timed at 6 a.m. through 12/14/2023 timed at 6:15 p.m., the licensed nurses documented that Resident 39's behavior was calm in response to the restraints. During a review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/9/2023 timed at 6 a.m. through 12/13/2023 timed at 4 a.m., indicated no documentation of Resident 39's right soft mitten and right soft wrist restraints were released every two hours for 15 minutes for blood circulation check. During a review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/11/2023 timed at 6 p.m. through 12/12/2023 timed at 8 a.m., indicated no documentation of Resident 39 was monitored every two (2) hours while on a right soft wrist restraint, and right-hand mitten restraint for blood circulation, and skin integrity. During a review of Resident 45's Restraint Every Two-hour Monitoring record dated 12/9/2023 at 10 a.m. through 12/14/2023 at 6:00 a.m., the licensed nurses documented that Resident 45's behavior was calm in response to the restraints (bilateral soft mittens). During a review of Resident 45's Restraint Every Two-hour Monitoring record dated 12/11/2023 at 12 a.m. through 12/11/2023 at 6 a.m., indicated no documentation that Resident 45's bilateral soft mittens were released every two hours for 15 minutes to check for circulation. During an interview on 12/13/2023 at 8:53 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated, Resident 68 right hand soft mitten should be released every two (2) hours for 15 minutes and during resident care and reapply after resident care was done. CNA 3 stated Resident 68 right hand soft mitten was not released during resident care. During an observation on 12/13/2023 at 9:29 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/13/2023 at 11:31 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/14/2023 at 9:03 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/14/2023 at 11:08 a.m., Resident 68 was observed with a right-hand soft mitten. During a review of Resident 11's Physician Order dated 8/16/2022, timed at 5:17 p.m., the Physician Order indicated to apply right hand mitten and right soft wrist restraint due to poor safety awareness secondary to poor cognition related to history of hemorrhagic stroke until discontinued. The Physician Order indicated to release the right soft restraint and right-hand mitten every two hours for 555848 Page 8 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 15 minutes and as needed for activities of daily living, skin, and blood circulation check. Level of Harm - Immediate jeopardy to resident health or safety During a review of Resident 11's Care Plan titled Restraints dated 8/2/2022, the Care Plan indicated to monitor for episodes of agitation (feeling of uneasiness) or anxiety (feeling of worry or nervousness), assess for less restrictive measures or devices prior to restraint use, check proper placement, release, and check for circulation, hygiene, and impaired skin integrity every two hours as interventions. Residents Affected - Some During a review of Resident 11's Restraint Every Two-hour Monitoring record dated 12/11/2023, indicated Resident 11 was not monitored from 8:26 p.m. to 6:00 a.m. on 12/11/2023. The Restraint Every Two-hour Monitoring record indicated monitoring was resumed on 12/12/2023 at 8:00 a.m. During an interview on 12/14/2023, at 11:52 a.m. with Director of Staff Development (DSD), DSD stated CNA and licensed vocational nurses (LVN) do a visual check of residents on restraints for proper placement every hour, and Hourly Patient Care Rounds log was posted on the door of the resident's room. DSD stated either the LVN or CNA will sign in after hourly checks and the registered nurses check if the LVN had completed the Hourly Patient Care Rounds logs. During a review of Resident 11's Hourly Patient Care Rounds log for residents at risk for removing essential lines from 11/2/2023 to 11/28/2023, the Hourly Patient Care Rounds log indicated hourly rounds were not signed on the following dates and times: 11/2/2023 from 7 a.m. to 10 a.m. and 6:00 p.m. 11/3/2023, at 5p.m. and 6:00 p.m. 11/4/2023 at 5 a.m.,10 p.m. to 12 a.m. 11/5/2023 at 1a.m. to 6 a.m., 9 p.m., 11p.m. 11/6/2023 at 1 a.m. ,3 a.m. and 5 a.m.,9 p.m., and 11p.m. 11/7/2023 at 3 a.m., 5 a.m., 7 p.m., and 9 p.m. 11/8/2023 at 11p.m. 11/9/2023 at 1 a.m., 3 a.m., and 5 a.m. 11/10/2023 at 9 p.m. and 11 p.m. 11/14/2023 at 7 p.m. and 10 p.m. 11/15/2023 at 12 a.m., 4 a.m., 6 a.m. and 7 p.m. 11/16/2023 at 1 a.m. and 5 a.m. 11/18/2023 at 9 a.m., 7 p.m., and 10 p.m. 11/19/2023 at 2 a.m., 6 a.m. 4 a.m., 9 p.m. and 11 p.m. 555848 Page 9 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 11/20/2023 at 6 p.m. Level of Harm - Immediate jeopardy to resident health or safety 11/21/2023 at 4 a.m., 5 a.m., and 6 a.m. Residents Affected - Some During a review of Resident 27's Physician Order dated 12/1/23, the Physician Order indicated, release restraints every two hours and check for skin redness, blood circulation, hydration, nutritional. 11/26/2023 at 6 p.m. During a review of Resident 27's Care Plan titled Absence of Harm or Injury, dated 3/12/23, indicated interventions including check for proper placement of the right-hand soft mitten and right soft wrist restraint; release and check for redness, circulation, hygiene, and impaired skin integrity every two hours and as needed. During a review of Resident 27's Restraint Every Two-hour Monitoring record dated 12/6/23 timed at 10:00 p.m. and 12/8/23 timed at 10 p.m., indicated Resident 27 has no documentation of Resident 27's right soft wrist restraint were released every two hours for 15 minutes for blood circulation check. During an interview on 12/15/2023 at 9:14 a.m., with RN 6, RN 6 stated if right hand soft mitten was not release from Resident 68's hands every two hours for 15 minutes, there was a possibility that will lead to decrease blood circulation. If the Resident 68's restraints were too tight it can lead to skin irritation or even pressure ulcer. During an interview on 12/15/2023 at 11:15 a.m., with CNA 5, CNA 5 stated soft hand mittens should be release every two hours for 15 minutes to prevent wrist pressure that can lead to pressure ulcer. During an interview on 12/15/23 11:16 a.m. with Registered Nurse (RN) 5, RN 5 stated the Restraint Every Two-hour Monitoring record were used for restraint assessment for residents (in general) to check for circulation because if the resident (in general) has poor circulation it can cause poor tissue perfusion (oxygen-rich blood delivered to the tissues in the body) and extremity (part of a limb of the body) could become necrotic. RN 5 stated, residents (in general) could feel frustrated, helpless, and hopeless from wearing physical restraints. During an interview on 12/15/2023 at 12 p.m. with RN 5, RN 5 stated, restrains should be released every two hours to assess for blood circulation and assess if restraint was applied too tight. RN 5 stated if a restraint was applied too tight it can cause harm including impeding blood circulation to the extremity, decrease tissue perfusion and the part of the body restrained can become necrotic and die. RN 5 stated, the risk for using all three restraints (soft mittens, soft wrist restraints and four siderails up) will impede a resident's movement. RN 5 stated, resident (in general) could become frustrated being tied up with a wrist restraint, soft mitten and all four siderails in an up position. During an interview on 12/15/2023 at 12:19 p.m. with NM 1, NM 1 stated resident (in general) with soft mittens, soft wrist restraints could result in impaired blood circulation, loss of movement, stasis ulcer if the resident was not assessed every two hours for 15 minutes. NM 1 stated, a pressure ulcer could occur, or an existing pressure ulcer could worsen, if the restraints are not being 555848 Page 10 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some released every two hours for 15 minutes or being assessed every two hours. NM 1 stated, if bilateral soft mittens are not removed or assessed every two hours for 15 minutes, it could result in a pressure ulcer or wound for a resident. 4. During a review of Resident 39's Care Plan titled Restraint Care dated 3/8/2018, indicated intervention included assess Resident 39 for least restrictive measures/devices prior to restraint use and to check for proper placement of restraints. The Care Plan indicated the goal was to discontinue the use of restraints on 6/8/2018. During a review of Resident 39's Nursing Progress Note dated 10/1/2023 at 10:22 a.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). During a review of Resident 39's Nursing Progress Note dated 10/15/2023 at 10:22 a.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). During a review of Resident 39's Nursing Progress Noted dated 11/5/2023 at 6:08 p.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mitten and right soft wrist restraint). During a review of Resident 39's Interdisciplinary ([IDT] a group of healthcare professional who assess, coordinate, and mange each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) Team Conference dated 9/21/2023, 10/19/2023 and 11/14/2023, indicated no documentation of the least restrictive measures were used and unsuccessful for Resident 39 prior to the placement of restraints (right soft mitten and right soft wrist restraints). During an interview on 12/15/2023 at 9:41 a.m. with NM 2, NM 2 stated least restrictive measures should be used prior to the initiation of restraints. NM 2 stated the residents (in general) might feel frustrated or angry while being in restraints. During a review of Resident 45's Care Plan titled At risk for social isolation and physical impairment dated 7/31/2023, indicated Resident 45 had potential for injury related to physical restraint use and had on bilateral soft mittens since 11/7/2023. The care plan interventions indicated Resident 45 should be assessed for the least restrictive measures prior to restraint use. During a review of Resident 45's Restraints weekly progress notes dated 11/19/2023, 11/26/2023, 12/3/2023 and 12/11/2023, indicated no documentation of least restrictive measures were used and unsuccessful with the continued use of bilateral soft mitten restraints. During a review of Resident 68's Care Plan titled Restraint non-behavioral dated 07/11/2023, indicated care plan interventions includes evaluate on-going need of restraint by assessing less restrictive measures/devices prior to restraint use, assess at least monthly for continued use of restraints and possible reductions, assess resident's response to restraints, release and check for redness, blood circulation, hygiene, and impaired skin integrity every two hours and as needed. 5. During an observation on 12/11/2023, at 11:52 a.m. in Resident 20's room, Resident 20 was awake, calm, lying in bed with bilateral upper and lower bed rails (a barrier attached to the side of a bed) were up and padded. Observed Resident 20 had a left soft wrist restraint with white plastic 555848 Page 11 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some buckle and hand mitten on the left wrist. The soft wrist restraint was tied in a knot and not tied in a quick release knot. During a concurrent observation and interview on 12/12/2023, at 12:30 p.m. with CNA 1, observed left soft wrist restraint of Resident 20 became tighter when head of bed was raised placed higher than thirty degrees. CNA 1 stated, CNAs make rounds to ensure the resident was repositioned, changed, restraint was in place and ensuring two fingers will fit under the soft wrist restraint and Resident 20's skin. CNA 1 stated LVN would assess the circulation and skin integrity every two hours. CNA 1 stated Resident 20 soft wrist restraints moved when the head of the bed was raised, and the soft wrist restraints got tighter on Resident 20's wrist. CNA 1 stated the facility was using a buckle to release the restraint instead of the quick release tie knot used in other facilities. During an observation on 12/12/2023, at 12:21 p.m. Resident 20 remained on four bedrails up, left-hand mitten and left soft wrist restraint with buckle was tied in a knot on the adjustable head part of the bed. During a concurrent observation and interview with on 12/12/2023 at 12:18 p.m. with LVN 12, observed Resident 39's restraint was tied in a knot on the bed. LVN 12 stated, the right wrist restraint was tied in the wrong place on a movable bed frame and there was a risk for injury for Resident 39. LVN 12 stated, it was the responsibility of the licensed nurses to assess and check placement of restraints (right soft mittens and right soft wrist restraint) every two hours. During a concurrent interview and record review on 12/14/2023 at 11:51 a.m. with the Director of Staff Development (DSD), the DSD observed the photo of placement of Resident 39's right soft wrist restraint and stated it was tied in the wrong place on the bed. The DSD stated the way Resident 39 restraint was tied; Resident 39 will not be able to use the call light to call for help. During an interview on 12/15/2023, at 12:22 p.m. with LVN 7, LVN 7 stated soft wrist restraint should not be tied on the adjustable head part of the bed because it could hurt the resident's wrist and tighten the restraint on the wrist, which had the potential to cause deep vein thrombosis (blood clot) due to poor circulation. During an observation 12/11/2023, at 11:39 a.m., observed Resident 11 lying in bed, asleep with tracheostomy to oxygen at 5 liters/ minute, right hand soft mitten, right soft wrist restraints with white plastic buckle and padded bilateral upper and lower bedrails were present and applied. Observed the right soft wrist restraint was tied tightly in a loop to the frame of the bed without using the method of a quick release knot. During a concurrent observation and interview on 12/11/2023, at 4:01 p.m. with Family Member (FM) 1, observed Resident 11's right soft wrist restraint and right-hand mitten were not present but padded bilateral lower and upper bedrails were in use. FM 1 stated she would release the right-hand mitten and right soft wrist restraint whenever she would visit because the staff members do not release the restraints most of the time that it would leave a mark on Resident 11's wrist. FM 1 showed a photo she took less than two weeks ago indicating a deep indentation on the right wrist. Observed the photo of Resident 11's right hand had skin discoloration and slight mottling (uneven, discolored patches on the skin due to lack of blood flow). During a review of Resident 11's Nursing Progress notes dated 11/22/2023 at 11:00 a.m., the Nursing Progress Notes indicated the FM expressed concerns about the tightness of right-hand soft mitten. 555848 Page 12 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0604 The Nursing Progress Notes indicate Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 555848 Page 13 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 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). Residents Affected - Some 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. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnoses including respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). During a review of Resident 3's quarterly Assessment Reference Date (ARD [the end date of the observation period and provides a common reference point for all team members participating in the assessment]) was completed on 10/5/2023 and was signed on 10/19/2023 by the MDS coordinator. During an interview on 12/13/2023 at 9:45 a.m., with the MDS coordinator, while reviewing Resident 3 MDS assessment, the MDS coordinator identified Resident 3 quarterly (every 3 months) assessment was not being transmitted timely (within 14 days) to the Centers for Medicare and Medicaid (CMS). During a concurrent interview and record review on 12/13/2023 at 2:59 p.m. with the MDS coordinator, the MDS coordinator stated the ARD for Resident 3 was not transmitted to CMS on 10/19/2023. The MDS coordinator stated it should have been sent within 14 days and it was an honest mistake. The MDS coordinator stated it was important to send the ARD on time to follow CMS regulations. During a review of the facility policy and procedure (P&P) titled Interdisciplinary Team Minimum Data Set Assessment revised 9/2023, the P&P indicated the quarterly ARD assessment was required to be submitted to CMS within 14 days. During a review of the Center for Medicare and Medicaid Services' Resident Assessment Instrument Version 3.0 Manual, Chapter 5, provided by the facility indicated that MDS assessments must be submitted 555848 Page 14 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). These deficient practices had the potential to cause Resident 11 to have intolerance to the feeding which could have caused diarrhea, nausea, vomiting, and aspiration (inhalation of foreign materials) which could lead to pneumonia (a lung infection), and had the potential to result in Resident 20 at risk for infection and inadequate nutrition. Findings: During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted on [DATE] with diagnoses including history of hemorrhagic stroke (blood vessels rupture in or near the brain which can cause permanent damage to the brain), tracheostomy, chronic respiratory failure, ileostomy (opening in the abdomen to evacuate stool from the body), anoxic brain injury( blood flow and oxygen to the brain was interrupted which can cause damage to the brain),and dysphagia ( difficulty of swallowing). During a review of Resident 11's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/15/2023, the MDS indicated Resident 11 had severely impaired cognitive skills( person had trouble remembering, learning, understand or make decisions that affect daily life) and was dependent on staff members with bed mobility, transfer from bed to wheelchair, bathing, toileting hygiene and personal hygiene. The MDS indicated Resident 11 had an indwelling catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) and ostomy (creation of an artificial opening in the abdomen to allow for the elimination of body wastes). During a review of Resident 11's Care Plan (CP), dated 5/18/23 and titled, Absence of Aspiration Signs and Symptoms the Care Plan indicated, Check for gtube residual every 8 hours., if 100 millimeters ([ml] small measurement) and greater hold for 1 hour then recheck. 2. During a review of Resident 20's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses that included deep venous thrombosis (blood clot formed in the deep vein of the body), history of traumatic brain injury (happens when a sudden, external, physical assault damages the brain),functional quadriplegia (complete immobility to move due to physical disability or frailty from other medical condition), gastrostomy( opening into the stomach from the abdomen for the introduction of food), presence of tracheostomy( an opening in the windpipe to provide alternative airway for breathing)), and history 555848 Page 15 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0693 of cerebrovascular attack(stroke, damage to the brain due to interruption of blood supply). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 20's MDS dated [DATE] the MDS indicated, the resident had severely impaired cognitive skillsand was dependent on staff members with bed mobility, bathing, personal hygiene, dressing and toileting hygiene. Residents Affected - Few During a review of Resident 20's Physician Order dated 12/12/2023 at 5:41 p.m. , the Physician Order indicated a continuous feeding of Isosource 1.5 (caloric dense and complete liquid nutrition) with a rate of 50 ml/hour for 22 hours until discontinued. During an observation on 12/11/2023, at 11:52 a.m. , Resident 20 was receiving tube feeding via feeding pump at 50 milliliters([ml] unit of measurement) per hour. Observed the tube feeding bag was not labeled with resident's name, formula name and strength, date, and time when it was hung and name of person who hung the tube feeding bag. During a concurrent observation and interview on 12/11/2023, at 12:02 p.m. with Licensed Vocational Nurse (LVN 6), LVN 6 confirmed the tube feeding bag was not labeled and the night shift must have hung it and forgot to properly label the bag. LVN 6 stated she should have dated and labeled the bag during her rounds because the resident could get sick from contaminated formula. During an interview on 12/15/2023, at 10:07 a.m. with Nurse Manager (NM2), NM 2 stated open system (formula from cans and bottles is poured into a feeding tube bag) tube feeding bag should be changed every eight hours and the licensed nurse should have labeled it with resident's name, name of formula, date, and time it was initially hung. NM2 stated it is important to know the expiration date of the formula so the licensed nurse will know when to take it down which can prevent infection and will ensure the resident is getting the correct formula. During an observation on 12/14/23 at 10:06 AM in Resident 11's room during medication pass the License Vocational Nurse (LVN 11 ), LVN 11 did not check the aspirate from Resident 11's gtube prior to administering of his medication. During an interview on 12/14/23 10:09 AM with LVN 11, LVN 11 stated prior to administering medications through the gtube the aspirate should be checked in order to ensure that the Resident 11 is tolerating the feeding. LVN 11 stated if Resident 11 is not tolerating the feeding his stomach could become distended (measurably swollen beyond its normal size), start vomiting, and aspirate (to breathe in, or to breathe a substance into your lungs by accident) and that's why it is important to check the residents (in general) aspirate from their gtube. During an interview on 12/14/23 11:02 AM with Nurse Manager (NM 1), the NM 1 stated, it is important prior to administering medication to a resident with a gtube because the resident might not be tolerating the feeding. NM 1 stated Resident 11's stomach could become distended, experience vomiting, aspirate and could get aspiration pneumonia. Nurse manager stated the facility policy indicates that the staff are to check the residual prior to giving medications. During a review of the facility's policy and procedure (P&P) titled, Tube Feeding Through Nasogastric Tube, Gastrostomy, or Jejunostomy Intermittent and continuous, dated 2023, the P&P indicated, Verify enteral tube placement using at least two of the following methods: .Observe for a change in the volume of aspirate from the enteral feeding tube because a large increase in volume may signal the upward dislocation of a small bowel feeding tube into the stomach. 555848 Page 16 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0693 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's LPN LVN Job Description, titled, Job Specific Knowledge, Skills, and Abilities dated 1900, indicated .Demonstrated competency in medication administration. During a review of the facility's New Hire Orientation for RN, LVN & CNA titled, Medication Administration, dated 2022, indicated Check placement .Gtube aspirate. Residents Affected - Few During a review of facility's policy and procedure (P/P) titled Tube feeding Through Nasogastric Tube, Gastrostomy, or Jejunostomy Intermittent and Continuous effective 11/20/2023, the P/P indicated to label the enteral (relating to or inside the intestines) administration set with the date and time it was first hung to prevent bacterial growth. The P/P indicated clinical staff who deliver enteral feeding through an open system is changed every eight hours and will label the feeding bag with patient's name, administration route, formula, date, time it was hung, and the initials of who hung it. 555848 Page 17 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

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 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: Residents Affected - Some 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. These deficient practices have the potential to result in harm and lead to development of infection, infiltration (accidental leakage of non-vesicant solutions out of the vein into the surrounding tissue) and phlebitis (inflammation of a vein) for Residents 92, 65 and 49. Findings: 1. During an observation on 12/11/2023 at 10:50 a.m. at Resident 65's bedside, it was observed that Resident 65 had a PIV on his left hand that was not dated or labeled. During a review of Resident 65's admission record (Face Sheet) dated 9/20/2023, the Face Sheet indicated Resident 65 was admitted to the facility with diagnoses of respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). During a review of Resident 65's Minimum Assessment Set (MDS - a standardized assessment and care screening tool) dated 10/1/2023, the MDS indicated Resident 65 had severe cognitive (ability to learn, remember, understand, and make decisions and memory impairment) for daily decision making. During a review of Resident 65's physician orders (PO) dated 11/12/2023, Resident 65 had a PO for IV therapy for antibiotics (medication used to treat infection) During an interview on 12/11/2023 at 10:52 a.m. with the Registered Nurse (RN 8), RN 8 stated the PIV site should be dated so they will know when it was inserted and when it should be changed to prevent infection. 2. During an observation on 12/11/2023 at 10:19 a.m. at Resident 92's bedside, it was observed that Resident 92 had extension tubing hanging at the bedside with no date on the tubing. During a review of Resident 92's admission record dated 11/13/2023, the Face Sheet indicated Resident 92 was admitted to the facility with diagnoses of respiratory failure and tracheostomy). During a review of Resident 92's MDS dated [DATE], the MDS indicated Resident 92 was alert, 555848 Page 18 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0694 oriented and able to make decisions regarding her activities of daily living (ADL's). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 92's physician orders (PO) dated 11/29/2023, the PO indicated Resident 92 had orders for the initiation of IV antibiotic therapy. Residents Affected - Some During an interview on 12/11/2023 at 10:22 a.m. with RN 8, RN 8 stated the IV tubing should have been dated. RN 8 stated the extension tubing is changed every four days and it should have been changed on 12/4/2023. RN 8 stated it was important to date the extension tubing so the licensed nurses will know when to change it and prevents infection. During an interview on 12/15/2023 with the Nurse Manager (NM 2), NM 2 stated, the PIV site needs to be dated so the licensed nurses will know when the site needs to be changed. NM 2 stated, they changed the PIV site every seven days to prevent infection at the site. NM 2 stated, all IV extension tubing need to be dated and it is the responsibility of the RN to date it and remove it when therapy is completed. 3.During a review of Resident 49's admission Record (Face Sheet), indicated Resident 49 was admitted to the facility on [DATE], with diagnoses including quadriplegia (paralysis of all four limbs), spinal cord stroke (disruption in the blood supply can cause injury or damage to tissues and can block messages (nerve impulses) travelling along the spinal cord), deep vein thrombosis ([DVT] occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs), and respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). During a review of Resident 1's MDS dated [DATE], The MDS indicated, Resident 49 had the ability to express ideas and wants. Resident 49 was total dependent (required full assistance from staff) with bed mobility, toilet use, hygiene. During an observation on 12/11/23 at 12:42 p.m. in Resident 49's room, the resident had ampicillin (a medication used to manage and treat certain bacterial infections) infusing to his left foot and it appeared to be swollen. Resident 49's left foot appeared bigger than his right foot in comparison. During an interview on 12/11/23 at 12:44 p.m. Resident 49 stated that he does not have pain to his left foot because he does not have feeling in his lower extremities due to being a quadriplegic. During a concurrent observation and interview on 12/11/23 01:48 p.m. with Registered Nurse (RN 1) in Resident 49's room, RN 1 stated the resident is on ampicillin for a urinary tract infection ([UTI] an infection that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract). RN 1 stated prior to giving IV therapy, the IV site should be assessed for redness, swelling and pain. RN 1 stated IVs are assessed every shift, also before and after starting IV medications. RN 1 stated, the IV site should be cleaned with alcohol and a saline flush (used to push any residual medication or fluid through the IV line and into your [vein]- a blood vessel that carries blood that is low in oxygen content from the body back to the heart) is used to ensure that residents (in general) IV's are patent. RN 1 stated Resident 49's IV should also be checked for blood return (the presence of blood return indicates the cannula is appropriately located within the patient's vein) to ensure that the IV is in the vein. RN 1 observed flushing Resident 49's IV site and checking for blood return to ensure proper placement. RN 1 confirmed that Resident 49's IV site did not have any blood return when observed, which could be an indication that the IV is not in the proper 555848 Page 19 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some place and could be infusing into Resident 49's tissue. RN 1 stated Resident 49's foot is swollen and IV site is infiltrated. During a concurrent interview and record review on 12/13/23 at 3:34 p.m. with Registered Nurse (RN 4), RN 4 stated Resident 49 currently has his IV to his right ankle, RN 4 confirmed after review of Resident 49's progress notes that there was no documentation indicating that the doctor was notified of the change of condition for Resident 49 swollen foot. RN 4 stated a doctor's order is necessary in order to start an IV. During a concurrent interview and record review on 12/13/23 at 3:59 p.m with Nurse Manager (NM 1), the NM 1 stated, to insert an IV a doctor's order is necessary and is the facility's policy. NM 1 stated the RNs should assess the IV site for redness, swelling, and signs of infection. NM 1 stated prior to administering medication through the IV the RN is supposed to flush the IV site and there should not be swelling, no resistance, and there should be blood return in order to ensure the IV is in the vein. NM 1 stated the facility's P&P indicates that a doctor's order should be obtained prior to inserting an IV. NM 1 stated, if a nurse inserts IV without a doctors order they are working outside of their scope of practice. NM 1 confirmed after a review of Resident 49's doctor's orders that there was no doctor order for a IV insertion. During a review of the facility policy and procedure (P&P) revised 5/2023, the P&P indicated PIV sites will be labeled, indicating the date of insertion. The P&P indicated IV tubing will be changed every 96 hours and all IV tubing must have a date and time the tubing is to be changed. 555848 Page 20 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0695 Provide safe and appropriate respiratory care 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 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. Residents Affected - Few 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. Findings: During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including history of hemorrhagic stroke (blood vessels rupture in or near the brain which can cause permanent damage to the brain), tracheostomy (opening in the windpipe that provides an alternative airway for breathing), chronic respiratory failure( occurs when the lungs cannot get enough oxygen into the blood which makes it difficult to breathe), ileostomy (opening in the abdomen to evacuate stool from the body), anoxic brain injury( blood flow and oxygen to the brain was interrupted which can cause damage to the brain), and dysphagia ( difficulty of swallowing). During a review of Resident 11's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/15/2023, the MDS indicated the Resident 11 had severely impaired cognitive skills (person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was dependent on the staff members with bed mobility, transfer from bed to wheelchair, bathing, toileting hygiene and personal hygiene. The MDS indicated Resident 11 had an indwelling catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) and ostomy (creation of an artificial opening in the abdomen to allow for the elimination of body wastes). During a concurrent observation and interview on 12/13/2023, at 2:43 p.m. with Family Member (FM) 1, observed Resident 11 had a tracheostomy connected to oxygen at five (5) litersper minute (L-unit of measurement). FM 1 stated Resident 11's portable oxygen tank was empty when they were in the patio and FM 1 informed Licensed Vocational Nurse (LVN) 8 about the empy portable oxygen tank FM 1 stated the Resident 11 was brought back to his room because the portable oxygen tank was empty. During a review of Resident 11's Respiratory Assessment Interventions dated 12/13/2023, the Respiratory Assessment Interventions indicated Resident 11 was assessed by Respiratory Therapist (RT) 1 at 7:50 a.m., 11:00 a.m., and at 2:45 p.m. During an interview on 12/13/2023, at 3:05 p.m. with RT 1, RT 1 stated Resident 11's oxygen could be set up by LVN and Registered Nurses (RN). RT 1 stated the Resident 11 was on oxygen at 2 liters via tracheostomy and when he checked Resident 11 at 11:45 a.m., the dial of the oxygen pressure gauge was not yet on the refill section. RT 1 stated Resident 11 could get short of breath or desaturate (low oxygen in the blood) if the portable oxygen tank did not have enough oxygen when he was in the patio or activity room. During an interview on 12/13/2023, at 4:15 p.m. with LVN 8, LVN 8 stated at 11:30 a.m. she set up the oxygen tank for Resident 11 when he was in the wheelchair to attend bingo game activity in the 555848 Page 21 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dining area and was accompanied by FM 1. LVN 8 stated the dial of the oxygen pressure was close to red (refill section) and thought the oxygen tank would be okay to be used by Resident 11. LVN 8 stated that she did not check the resident (Resident 11) till around 2:00 p.m. because she was busy, and the family member was with the resident. LVN 8 stated there was no designated staff member to supervise or check residents who are in the patio. LVN 8 stated Resident 11 could run out of oxygen and desaturate if he was on an empty portable oxygen tank while attending acitivit or in the patio. During an interview on 12/13/2023, at 4:37 p.m. with Certified Nursing Assistant (CNA7), CNA 7 stated she got up Resident 11 into the wheelchair and the RT or LVN 8 hooked up the resident to the oxygen tank. CNA7 stated the resident went into dining area for the bingo game at 11:15 a.m. and there was no designated staff assigned to supervise residents when the residents are in the patio. During an interview on 12/14/2023 at 4:45 p.m. with RN 5, RN 5 stated it was the responsibility of the primary nurse to check the potable oxygen tank had enough oxygen for the resident (Resident 11) to use while outside the room. RN 5 stated if the oxygen tank's gauge needle was close to the refill section, the nurse should have changed the oxygen tank to prevent resident's desaturation. During an interview on 12/15/2023, at 11;48 a.m. with RT 3, RT 3 stated portable oxygen tank with the dial close to the red refill section would be empty within thirty to one hour of use for resident on oxygen at 5 liters/minute. RT 3 stated he would not use portable oxygen tank that was close to the refill section if a resident will be in the dining area for an activity and then in the patio area. During a review of facility's policy and procedure (P&P) titled Oxygen Handling revised 10/2020, the P&P indicated oxygen tanks that are full was indicated by the gauge needle pointing in the green section of the gauge face and gauge needle in the red was considered empty. Tanks are to be checked prior to each use and replaced as necessary for the needed transport time. 555848 Page 22 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. at Resident 39's bedside, Resident 39 was observed non-verbal with a soft wrist restraint on the right wrist, a soft mitten restraint on the right hand and all four siderails up on the bed. During a review of Resident 39's admission Record (Face Sheet) the Face Sheet indicated Resident 39 was admitted on [DATE] with diagnoses including respiratory failure (a condition in which your blood doesn't have enough oxygen), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck) and cerebral vascular accident (CVA[ an interruption in the flow of blood to cells in the brain]) with left arm weakness. During a review of Resident 39's Minimum Assessment Set (MDS - a standardized assessment and care screening tool) dated 11/10/2023, the MDS indicated Resident 39 had severe cognitive (ability to learn, remember, understand, and make decisions) and memory impairment for daily decision making. Resident 39 had impairment (weakness) on both arms and was dependent for all activities of daily living (ADLconsist of eating, dressing/grooming, bathing/personal hygiene, mobility (ambulation and transfer), elimination (toileting). The MDS indicated Resident 39 used one limb (right arm) physical restraints on the right upper extremity and did not use bed rails for restraints. During a review of Resident 45's admission Record (Face Sheet) the Face Sheet indicated Resident 45 was admitted on [DATE] with diagnoses including respiratory failure, dementia (a condition characterized by progress loss of intellectual functioning with memory impairment), and status post fall. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severe cognitive impairment for daily decision making. Resident 45 had impairment on both arms and was dependent for all ADL. The MDS indicated Resident 45 had bilateral (both) hand restraints and did not use bed rails for restraints. During a review of Resident 20's admission Record (Face Sheet ), the Face Sheet indicated Resident 20 was admitted on [DATE] and readmitted on [DATE] with diagnoses including deep venous thrombosis (blood clot formed in the deep vein of the body), history of traumatic brain injury (damage to the 555848 Page 23 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some brain that disrupts normal functioning caused by an outside force, typically such as a violent blow to the head), functional quadriplegia (complete immobility to move due to physical disability or frailty), gastrostomy (opening into the stomach from the abdomen for the introduction of food), presence of tracheostomy, and history of CVA. During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20 had severely impaired cognitive skills and was dependent on staff members with bed mobility, bathing, personal hygiene, dressing and toileting. The MDS indicated Resident 20 was on upper limb restraint. The MDS indicated Resident 20 was on limb restraint but bilateral lower and upper siderails were not used by resident. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted on [DATE] with diagnoses including history of hemorrhagic stroke (blood vessels rupture in or near the brain which can cause permanent damage to the brain), tracheostomy, chronic respiratory failure, ileostomy (opening in the abdomen to evacuate stool from the body), anoxic brain injury( blood flow and oxygen to the brain was interrupted which can cause damage to the brain),and dysphagia ( difficulty of swallowing). During a review of Resident 11's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/15/2023, the MDS indicated Resident 11 had severely impaired cognitive skills and was dependent on staff members with bed mobility, transfer from bed to wheelchair, bathing, toileting hygiene and personal hygiene. The MDS section indicated no bedrails were used for the resident but only limb restraint. During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated Resident 68's was admitted on [DATE] with diagnoses including aneurysm (an abnormal bulge or ballooning in the wall of a blood vessel), subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), cerebral edema (swelling of the brain), tracheostomy and gastrostomy. During a review of Resident 68's MDS dated [DATE] indicated Resident 68 had severe cognitive impairment and requires total assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident 68 used limb (right arm) restraint daily. During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted on 8/2014, with diagnoses including traumatic brain injury, epilepsy (seizure disorder sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), dysphagia, respiratory failure tracheostomy and gastrostomy. During a review of Resident 27's History and Physical (H/P), dated 1/3/23, the H/P indicated, Resident 27 did not have the ability to communicate. During a review of Resident 27's MDS dated [DATE], the MDS indicated, Resident 27 had persistent vegetative state/no discernible consciousness (when a person is awake but is showing no signs of awareness). Resident 27 required extensive assistance (resident total dependent; full staff assistance) with bed mobility and extensive assistance with transferring, dressing, toilet use, personal hygiene and did not utilize a mobility device. The MDS indicated Resident 27 utilized a limb (right arm) restraint daily. 555848 Page 24 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 12/11/2023, at 11:39 a.m., Resident 11 was lying in bed, asleep with tracheostomy to oxygen at five liters/ min ([L] unit of measurement), right hand soft mitten, right soft wrist restraint and padded bilateral upper and lower bedrails. During a review of Resident 11's Physician Order dated 12/11/2023 timed at 6:47 p.m., the Physician Order indicated hospital bed with siderails, bilateral upper and lower padded siderails up for seizure precautions until discontinued. During a review of Resident 11's Physician Order dated 8/16/2022 timed at 5:16 p.m., the Physician Order indicated an order of leviteracetam (medicine to treat seizures) 500 milligrams ([mg] unit of measurement) per gastrostomy tube (G-tube, flexible tube placed directly into the stomach to give direct access for feeding, water and medicine) twice a day. During a review of Resident 11's Nursing Progress Notes dated 11/1/2023 to 12/13/2023, the Nursing Progress Notes indicated no episodes of seizure was documented. During a review of Resident 11's Medication Administration Record (MAR) dated 12/6/2023 to 12/14/2023, the MAR indicated no monitoring of seizures was documented. During a subsequent observation on 12/12/2023 at 8:30 a.m. and 12/14/2023 at 8:05 a.m., in Resident 11' room, observed bilateral padded upper and lower bedrails were in use in addition to the use of right-hand soft mitten and right soft wrist restraint were present. During a review of Resident 20's Physician Order dated 10/19/2023 timed at 11:45 p.m., the Physician Order indicated bilateral upper and lower side rails padded for safety and for the diagnosis of seizure until discontinued. During a review of Resident 20's Physician Order dated 10/19/2023, the Physician Order indicated an order for lacosamide (medicine to treat seizures) 200 mgs. per G-tube twice a day, Keppra 1,750 mgs (medicine to treat seizures) mgs per G-tube twice a day, Dilantin (medicine to treat seizures)300 mgs. per G-tube twice a day and Topamax (medicine to treat seizures)100 mgs per G-tube twice a day. During a review of Resident 20's Nursing Progress Notes dated 11/1/2023, to 12/12/ 2023, the Nursing Progress Notes indicated the Resident 20 did not have episodes of seizures. During a subsequent observation on 12/11/2023, at 11:52 a.m. 12/12/2023, at 12:21 p.m., Resident 20 was lying in bed with bilateral padded upper and lower siderails in place. During an interview on 12/15/2023, at 12:22 p.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated residents (in general) on bilateral upper and lower siderails up was considered a form of restraint because there was a risk of entrapment and residents (in general) could get injured. LVN 7 stated Resident 20's electronic medical record indicated the facility does not document the monitoring of bilateral lower and upper bedrails use. During an interview on 12/15/2023 with RN 5, RN 5 stated, the risk for using all three restraints (soft mittens, soft wrist restrains and four siderails up) will impede a resident's movement. RN 5 stated the risk for using four side rails will impede a resident mobility and can increase the risk of entrapment. RN 5 stated, a resident could become frustrated from being tied up with a wrist restraint, mitten and all four siderails. 555848 Page 25 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/15/2023 at 12:19 p.m. with Nurse Manager (NM) 1, all four siderails up could result in entrapment, resulting in injury of a resident (in general). During a review of the facility policies and procedures (P&P) titled Bedrails revised 9/2022, the P&P indicated Using bedrails that keep a resident from voluntarily getting out of bed is considered a restraint. It is the responsibility of the registered nurse (RN) to complete the Bed Rail Use and Entrapment Risk Assessment on admission, quarterly, annually and with change of condition. It is the responsibility of the licensed nurse to review with the family and or resident the risks and benefits of bed rail use. 555848 Page 26 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. These deficient practices resulted in Resident 49 having an IV inserted into his left foot without a physician's order (a formal request for a specific action to be carried out by the medical staff, such as administering a medication, conducting a diagnostic test, or providing a certain type of care to a patient) and subsequently the left foot IV became infiltrated (when some of the fluid leaks out into the tissues causing swelling, pain, or burning in the IV area), and swollen (puffed up) Findings: During a review of Resident 49's admission Record (Face Sheet) , indicated Resident 49 was admitted to the facility on [DATE], with diagnoses including quadriplegia (paralysis of all four limbs), spinal cord stroke (disruption in the blood supply can cause injury or damage to tissues and can block messages (nerve impulses) travelling along the spinal cord), deep vein thrombosis ([DVT] occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs), and respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). During a review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and care screening tool], dated 6/13/23, The MDS indicated, Resident 49 had the ability to express ideas and wants. Resident 49 was total dependent (required full assistance from staff) with bed mobility, toilet use, hygiene, lower extremity impairment on both sides and did not utilize a mobility device. During an observation on 12/11/23 at 12:42 p.m. in Resident 49's room, Resident 49 had ampicillin (a medication used to manage and treat certain bacterial infections) infusing to his left foot. Observed left foot with IV was swollen. Resident 49's left foot appeared bigger than his right foot in comparison. During an interview on 12/11/23 at 12:44 p.m. with Resident 49, Resident 49 stated he does not have pain to his left foot because he does not have feeling in his lower extremities due to being a quadriplegic. During a concurrent observation and interview on 12/11/23 01:48 p.m. with Registered Nurse (RN) 1 in Resident 49's room, RN 1 stated Resident 49 was receiving ampicillin for a urinary tract infection ([UTI] an infection that happen when bacteria, often from the skin or rectum, enter the urethra, 555848 Page 27 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and infect the urinary tract). RN 1 stated prior to giving IV therapy, the IV site should be assessed for skin redness, swelling and pain. RN 1 stated IV site were assessed every shift, also before and after starting IV medications. RN 1 stated, the IV site should be cleaned with alcohol and a saline flush (used to push any residual medication or fluid through the IV line and into your [vein]- a blood vessel that carries blood that is low in oxygen content from the body back to the heart) was used to ensure that residents (in general) IV's are patent. RN 1 stated Resident 49's IV should also be checked for blood return (the presence of blood return indicates the cannula is appropriately located within the patient's vein) to ensure that the IV was in the vein. Observed RN 1 flushed Resident 49's IV site and checked for blood return to ensure proper placement. RN 1 stated that Resident 49's IV site did not have any blood return when observed, which could be an indication that the IV was not in the proper place and could be infusing into Resident 49's tissue. RN 1 stated Resident 49's foot was swollen and IV site was infiltrated. During a concurrent interview and record review on 12/13/23 at 3:34 p.m. with RN 4, RN 4 stated Resident 49 currently has his IV to his right ankle, RN 4 stated after review of Resident 49's Nursing Progress Notes that there was no documentation indicating that the physician was notified of the change of condition for Resident 49 swollen left foot. RN 4 stated a physician order was necessary in order to start an IV on Resident 49's foot. During a concurrent interview and record review on 12/13/23 at 3:59 p.m. with Nurse Manager (NM) 1, the NM 1 stated, to insert an IV a physician order was necessary and was the facility's policy. NM 1 stated the RNs should assess the IV site for skin redness, swelling, and signs of infection. NM 1 stated prior to administering medication through the IV the RN was supposed to flush the IV site and there should not be swelling, no resistance, and there should be blood return in order to ensure the IV was in the vein. NM 1 stated the facility's P&P indicates that a physician's order should be obtained prior to inserting an IV. NM 1 stated, if a nurse inserts IV without a physicians order they are working outside of their scope of practice. NM 1 stated after a review of Resident 49's Physician Order, there was no physician order for a IV insertion. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Vascular Access Management, dated 2023, the P&P indicated, A physician's order is required to perform venipuncture and initiate IV therapy. During a review of the facility's policy and procedure (P&P) titled, Medication Management, dated 2023, the P&P indicated, Medications may be administered on the order of a licensed physician/prescriber with clinical privileges by an RN, LVN or other licensed provider in accordance with their scope of licensure. 555848 Page 28 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0759 Ensure medication error rates are not 5 percent or greater. 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: Residents Affected - Few 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. Findings: During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including respiratory failure (condition when the lungs cannot get enough oxygen to meet body's demands), seizure(uncontrolled electrical activity between brain cells causing temporary abnormalities in muscle tone or movement), tracheostomy (an opening in the windpipe to provide alternative way for breathing), and right hemiplegia ( right sided weakness or paralysis on the right side of the body). During a review of Resident 30's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/8/2023, the MDS indicated Resident 30 had severely impaired cognition (ability to learn, remember, understand, and make decisions) and was dependent on staff members with bed mobility, toileting, hygiene, bathing, dressing and personal hygiene. During an observation during medication pass on 12/14/2023, at 10:05 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 did not administer to Resident 30 the following medications: 1.Triamcinolone (steroid topical cream used to treat various skin condition and itching) .1% ( concentration of medicine) cream to left and right groin. 2.Ketoconazole 2% shampoo (medicine to treat fungal infection) During a review of Resident 30's Physician Order dated 12/13/23, the Physician Order indicated an order for ketoconazole 2% shampoo, apply damp skin, lather, and leave on for five (5) minutes twice weekly. During a concurrent interview and record review on 12/14/23 with Registered Nurse (RN) 5, reviewed Resident 30's Medication Administration Record (MAR) dated 12/14/23, at 4:59 p.m., RN 5 stated Ketoconazole shampoo and triamcinolone cream were not administered on 12/14/2023, at 9:00 a.m. RN 5 stated physician should be notified if a medication was not given to the resident and document the reason it was not administered in the MAR or Nursing Progress Notes. 555848 Page 29 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0759 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 12/14/2023, at 5:47 p.m. with Clinical Pharmacist (CP) 1, CP1 stated Ketoconazole shampoo and triamcinolone cream were not administered on 12/14/2023 at 9:00 a.m. and no documentation indicating reasons why the medications were not administered. CP 1 stated omission of medication (event in which an appropriate medication was not provided to a patient) was considered a medication error. Residents Affected - Few During a review of facility's policy and procedure (P&P) titled Medication Management revised 6/2023, the P&P indicated to always observe the five rights of administering each medication as follows: 1. Right patient 2. Right medication 3. Right dose 4. Right time 5. Right route/ method of administration 6. Additional rights to be considered for safe medication include right documentation, right action, right form, and right response. 2. During a medication pass observation on 12/14/2023, at 10:05 a.m. with LVN 5, LVN 5 entered Resident 30's room, stated Resident 30's last name and scanned his wristband without checking resident identification band for name and date of birth . During an interview on 12/14/2023, at 2:35 p.m. with LVN 3, LVN 3 stated they just scan the wristband to identify the resident's name and date of birth during administration of medication. LVN 3 stated once you scan the resident's wristband the picture of the resident name and date of birth of resident will show in the computer screen. During an interview on 12/14/2023, at 4:59 p.m. with RN 5, RN 5 stated licensed nurses should check the resident's identification band to verify if the name and date of birth was the same with the resident's medical record before scanning to prevent giving wrong medication that could harm the resident. During an interview on 12/15/2023, at 10:07 a.m. with Nurse Manager (NM) 2, NM 2 stated licensed 555848 Page 30 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursed should check the identification band for resident's name and date of birth and then scan it before administering medications to verify if it was the right resident. NM 2 stated verifying if it's the correct resident will prevent medication error and potential harm to the resident. During a review of facility's P&P titled Medication Management revised 6/2023, the P&P indicated to identify the patient prior to giving medication by always checking the patient's ID before administration of medication. The P&P indicated two patient identifiers are full name and date of birth should be checked and if date of birth is not on the band, patient's name and medical record number will be used to identify the patient. 555848 Page 31 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

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 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. Findings: During a facility kitchen tour observation on 12/11/2023 at 9:35 a.m., observed multiple canned foods with no received date, observed multiple seasoning goods that were opened but not labelled with open date. During an interview on 12/11/2023 at 9:40 a.m. with the Dietary Director, stated that all canned foods, meat products, and vegetables delivered to the kitchen pantry should have a received date and expiration date. During a facility kitchen tour observation on 12/11/2023 at 9:45 a.m., observed facility freezer and refrigerator with packed chicken breasts wrapped in a transparent plastic wrapper and vegetables with no receive date. During an interview on 12/11/2023 at 9:55 a.m., the Dietary Director stated that the facility kitchen freezer and refrigerator must have a uniformity of labeling foods and must stamp a date to all goods including dry goods and specially all kinds of meat once the package was open and must have an expiration date. During a tray line (a process of preparing and setting food for the residents in the facility) observation on 12/13/2023 at 11:43 a.m., observed [NAME] 2 serving plastic spoon and scoop and transferred food to the plate and placed the plastic serving spoon to the soiled area and repeated the process three times and did not change the spoon. During an interview on 12/13/2023 at 3:05 p.m., with the Dietary Director stated that the plastic spoon should not be use many times to transfer food from the tray line serving dish to a plate and place the spoon to the soiled and dirty area and use it repeatedly. The Dietary Director stated that it was an infection control issue. During an interview on 12/13/2023 at 2:19 p.m., with the Dietary Supervisor, the Dietary Supervisor stated that a serving spoon must stay in the serving dish and does not need to be place in a dirty area and be place back to the serving dish again and use the process repeatedly because it is an infection control issue. 555848 Page 32 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0812 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled Storage of Foods/Discard Dates Revised 10/2017, indicated to provide pull date guidelines to help ensure that safe, unspoiled foods are served to all our patients and other customers and all foods must be properly covered, labeled, and dated. Residents Affected - Many 555848 Page 33 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based 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: Residents Affected - Some 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). These deficient practices placed for 12 residents out 95 who were on physical restraints (devices that limit a patient's movement) at risk for impaired blood circulation with possible formation of venous stasis ulcers (medical condition characterized by impaired blood flow in the veins), skin injuries including pressure ulcer (an injury that breaks down the skin and underlying tissue) and psychosocial harm from not being treated with respect and dignity. Cross reference F604 Findings: During a concurrent interview and record review on 12/15/2023 at 9:06 a.m. with the Director of Nurses (DON), the DON stated, every year the facility looks at quality assurance and performance improvement areas on what issues were arising to see what issues to focus on like psychotropic drugs (medications that affect the mind, emotions, and behavior), catheter associated urinary tract infections (CAUTI- urinary tract infection [infection in the urine]associated with urinary catheter use) and restraints. The DON stated restraints was discussed in the last QAPI meeting in the third quarter 2023. The DON stated, the facility did restraint audits and in September 2023 the weekly assessment done by the Registered Nurse (RN) was at 92% and not in compliance at 100%. The DON stated, no re-education was done with the RN's during September 2023 audit. During a review of the facility policy and procedure (P&P) dated 2023-2024 titled, QAPI plan, the P&P indicated the QAPI program will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents by ensuring data collection tools and monitoring systems are in place and are consistent for a proactive analysis. The P&P indicated the facility will utilize the best available evidence to define and measure the facility goals. The P&P indicated they will work to improve the organization performance by reducing and/or eliminating preventable and unanticipated outcomes and manage actual or potential risks to safety. 555848 Page 34 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

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 observation, interview, and record review, the facility failed to observe infection control measures by failing to: Residents Affected - Some 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. These failures had a potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for spread of infection. Findings: 1.During a medication pass observation on 12/14/2023, at 10:05 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 crushed pills with gloves on and proceeded to discard used gloves to the trash container. LVN 5 put on a new pair of gloves without washing hands or using an alcohol-based hand rub ([ABHR] alcohol containing preparation in the form of liquid, gel or foam to sanitize hands) and administered medications to the resident. Observed LVN 5 not performing hand hygiene after removal of gloves. During an interview on 12/14/2023, at 10:28 a.m. with LVN 5, LVN 5 stated she did not perform hand hygiene when putting on new pair of gloves because her hands were already clean, and her hands could get sticky from the ABHR, and this could lead to the tearing of the gloves. During an interview on 12/14/2023, at 11:18 a.m. with Infection Preventionist Nurse (IPN) 2, IPN 2 stated hand hygiene was performed after taking off a pair of gloves and before putting a new pair of gloves because wearing a new pair of gloves without hand hygiene was not 100 percent foolproof for cleanliness. IPN 2 stated hand hygiene was practiced in preventing spread of infection. During an interview on 12/14/2023, at 2:55 p.m. with Registered Nurse (RN) 5, RN 5 stated hand hygiene should be performed every time gloves were changed and removed to prevent spread of infection. 2. During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was admitted on [DATE] to the facility with diagnoses including respiratory failure (condition when the lungs cannot get enough oxygen to meet body's demands), seizure(uncontrolled electrical activity between brain cells causing temporary abnormalities in muscle tone or movement), tracheostomy (an opening in the windpipe to provide alternative way for breathing), and right hemiplegia (right sided weakness or paralysis on the right side of the body). 555848 Page 35 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 30's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/8/2023, the MDS indicated Resident 30 had severely impaired cognition (ability to learn, remember, understand, and make decisions) and was dependent on the staff members with bed mobility, toileting hygiene, bathing, dressing and personal hygiene. During a medication pass observation on 12/14/2023, at 10:10 a.m. with LVN 5. LVN 5 brought a portable BP machine inside Resident 30's room and took his BP before administration of medication. Observed Resident 30 was on Enhanced Standard Precaution Isolation (resident-centered and activity-based approach for preventing multi-drug resistant organism [MDRO- germ that is resistant to a lot of antibiotics] transmission in skilled nursing facilities).LVN 5 did not clean or disinfect the BP machine, brought the BP machine out of Resident 30's room and stationed it on the hallway. During an interview on 12/14/2023, at 11:18 a.m. with IPN 2, IPN 2 stated BP machine should be cleaned and sanitized in between use of residents to prevent spread of infection. 3. During an observation on 12/11/2023 at 12:22 p.m., observed certified nursing assistant (CNA) 1 walking in the hallway with gloves and gown on. During an observation on 12/12/2023 at 4:50 p.m., observed LVN 2 placed the used gown that she wore to provide care and put it on top of the medication cart and did not wash her hands. During an interview on 12/14/2023 at 10:41 a.m., with registered nurse (RN) 4, RN 4 stated that when any staff used the gown and enters the resident room for protection, used gown must be discarded inside the container bin designated for the used gown inside the resident room and should not be worn outside the resident room and in the hallway for infection control. RN 4 stated that it should not be place on top of a medication cart after the gown had been used and must wash their hands before and after using the Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) because there was a possibility to spread the infection. During an interview on 12/14/2023 at 12:57 p.m., with LVN 2, LVN 2 stated all staff must dispose the used PPE in the designated trash bin located inside the resident room and wash hands after every use of PPE. LVN 2 stated used gown must never be place on top of the medication cart because for infection control. During a review of facility's policy and procedure (P&P) titled Hand Hygiene Policy revised 9/2019, the P&P indicated gloves are removed when the need for protection no longer exists and hand hygiene should be practiced immediately after removal of gloves. The P&P indicated hand hygiene will be performed before or after the following activities: 1.Upon entering patient room, before patient contact 2. Upon exiting patient room, after patient contact 3. After contact with patient surroundings 4. Before putting and after removing PPE( Personal Protective Equipment, specialized clothing or equipment worn by an employee for protection against infectious materials) 555848 Page 36 of 37 555848 12/14/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0880 5. Before putting on gloves and after taking off gloves. Level of Harm - Minimal harm or potential for actual harm During a review of facility's P&P titled Cleaning of Moveable Medical Equipment revised 5/2021, the P&P indicated non-dedicated (shared equipment among residents) equipment should be cleaned after each individual use. The P&P indicated only hospital approved disinfectants will be used for disinfection and per manufacturer's instructions for proper use of disinfectant. Residents Affected - Some During a review of the facility's P&P titled Donning and Doffing Personal Protective Equipment (PPE) revised 10/2021, indicated: PPE was to be properly donned put on) and doffed (removed) in the proper sequence, and adjusted and worn properly in order to reduce the risk of contamination. To reduce the risks of exposure to pathogens and prevent workplace illnesses for all staff, physicians, and volunteers. 555848 Page 37 of 37