Health inspection·January 16, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain infection control practices when: Residents Affected - Few 1.Certified Nursing Assistant 1 (CNA 1) provided care to Patient 2 then proceeded to Patient 1s bedside without changing CNA 1s personal protective equipment (PPE) gown prior to initiating care for Patient 1. 2.CNA 2 placed clean linen intended for Patient 1 on top of a used soiled linen cart and proceeded to Patient 1s bedside to initiate care. These deficient practices had the potential to cause cross-contamination (the unintentional physical movement or transfer of harmful bacteria from one person, object, or place to another) of infectious pathogens (bacteria and microorganisms) from patient to patient and/or within the facility. Findings: During an observation on 1/15/25 at 10:30 AM, an Enhanced Barrier Precautions ([EBP] measures that use gowns and gloves to reduce the spread of infection) sign is posted outside Patient 1s door which indicated when entering the room, providers and staff must apply a gown and gloves. This is a double occupancy room with the patients distinguished by bed A and bed B. During an interview with the Infection Control Preventionist (IP) on 1/22/25 at 3:33 PM, IP indicated Patient 1 is on EBP which requires glove and gown use during high-contact patient care activities with patients who have wounds and/or indwelling (inside your body) medical devices or are infected or colonized (presence of with an infection where contact precautions (set of practices used to prevent the spread of infectious diseases) do not apply. EBPs are to be observed in addition to standard precautions. Regarding gown/PPE changes between patients, caregivers are educated/trained to not use the same PPE for care of more than one patient. Donning and doffing (putting on and removal) of PPE, as well as hand hygiene practices are part of core infection prevention principles that caregivers are required to get training on upon hire and on a yearly basis. Other educational opportunities on infection prevention practices are also offered all throughout the year in addition to education when a missed opportunity is observed. During an interview with CNA 1 on 1/27/25 at 20:15 PM, CNA 1 reports helping bed A (Patient 2) change Patient 2s urinary pad. CNA 1 then took the PPE gloves off, performed hand hygiene and put on new gloves. CNA 1 indicated the PPE gown was not changed. CNA 1 stated the gown was not changed due to not thinking clearly. CNA 1 stated this was due to bed B (Patient 1) requesting assistance. CNA 1 reports wanting to act quickly for bed B and forgot to change the gown. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555848 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)