Other·August 16, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represent the finding of the Department of Public Health during Recertification survey. Representing the Department of Public Health: Surveyor ID #: 39085, RN, HFEN Surveyor ID #: 34396, RN, HFEN Surveyor ID #: 36356, RN, HFEN Surveyor ID #: 37702, RN, HFEN Surveyor ID #: 38600, RN, HFEN Surveyor ID #: 32022, Pharmacy Consultant Total Census: 109 Sample Size: 41 Highest Severity and Scope: L The facility failed to ensure licensed and nonlicensed staff practiced proper infection control measures while providing care to residents on contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment) for 35 of 41 residents (73, 19, 96, 14, 1, 11, 75, 54, 86, 59, 7, 15, 87, 41, 84, 32, 64, 21, 53, 27, 35, 38, 101, 3, 6, 28, 48, 2, 10, 66, 354, 51, 97, 47, 205) with infections who were on contact isolation. The facility had six residents (4, 79, 91, 92, 62, and 82) that were not on contact isolation. According to the facility's document dated 6/28/19 titled, "Resident Census and Conditions of Resident," the facility census was 109 residents. The facility failed to: 1. Ensure staff performed hand hygiene before and after residents' care. 2. Ensure staff sanitized (to free from dirt, germs), shared equipment before and after LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 1 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents' use. 3. Ensure staff utilized personal protective equipment ([PPE] gowns, gloves, goggles for eye protection, and face masks) as indicated on the sign for 'Contact Isolation' signs posted outside the residents' room. 4. Ensure staff was removing PPE after having contact with a resident, the surrounding environment, medical equipment, and before leaving/exiting the contact isolation rooms. 5. Ensure staff were preventing hands and clothing from touching potentially contaminated environmental surfaces or items. 6. Ensure Environmental Services Staff (EVS 2) did not take the housekeeping cart inside a contact isolation room, and disinfect any supply brought to the rooms, at the end of the cleaning routine. On 7/2/19, the survey team identified an Immediate Jeopardy (IJ) related to lack of proper Infection Control practices and on the same day at 11:51 a.m., in the presence of Director of Nursing (DON) and Chief Executive Officer (CEO), the Survey Team called an IJ due to inadequate Infection Control practices. On 7/2/19 at 11:51 a.m., an Immediate Plan of Action (POA) was received and the corrective actions included the following: 1. Immediate education to all staff on proper infection control practices. 2. All equipment used with multiple residents (portable computer workstations, carts, environmental surfaces, etc.) would undergo disinfection and cleaning. 3. An audit tool was revised to include monitoring disinfection of multi-resident use equipment before and after use of a resident. On 7/3/19 at 2:07 p.m., the Team verified the corrective POA and accepted the POA. On 7/3/19 at 2:10 p.m., the IJ was lifted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 2 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F550 Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/16/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 3 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure four of four sampled residents (4, 79, 354) were treated with dignity and respect during care. This deficient practice resulted in exposure of Residents 4, 79, and 354 body parts, had the potential for exposure to cold temperatures, and possible lowering the resident's selfesteem. Findings: a. A review of the admission records indicated Resident 4 was admitted to the facility on 3/15/19, with diagnoses not limited cognitive (inability to learn, remember, make decisions and understand) impairment. A review of the Minimum Data Set (MDS), a standardized assessment, and care screening tool, dated 3/8/19 indicated Resident 4 had severe cognitive impairment. During an observation on 6/28/19 at 8:28 a.m., certified nurse assistant (CNA 2) performed range of motions ([ROM] how far you can move your joints in different directions) exercises to both of Resident 4's legs. The privacy curtains were partially closed, making Resident 4's incontinent brief (diaper) and both thighs exposed, and visible from the curtain openings. During observation, CNA 2 completely closed the curtains as soon she realized the resident was exposed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 4 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 7/05/19 at 7:13 a.m., CNA 2, stated "I am supposed to close the privacy curtain all the way so no one can see what I am doing, and provide privacy for the resident." CNA 2 stated by not closing the privacy curtains, Resident 4 was exposed, may cause the resident to feel embarrassed, it may lower their self-esteem, and dignity. b. A review of the admission record, indicated Resident 79 was admitted to the facility on 6/5/19, with diagnoses not limited to anoxic (brain is starved of oxygen for prolonged time) causing brain injury. A review of the H&P, dated 6/11/19, indicated Resident 79 responded minimally during neurological assessment (a branch of medicine concerned especially with the structure, function, and diseases of the nervous system). During an observation on 7/05/19 from 8:05 a.m. to 8:30 a.m., Resident 79 was observed in bed naked as CNA 4 performed a bed bath. CNA 4, to wash Resident 79, poured soapy water on the resident. Resident 79 was observed to pull both arms towards the face, shake, and had several goose bumps (bumps on the skin from fear or cold) on the body. A bed bath blanket, flat sheet, and several towels were observed on the bed side table of Resident 79. During an interview on 7/05/19 at 9:13 a.m., CNA 4 stated "I am supposed to cover a resident except for the body part I am working on during a bed bath." CNA 4 stated residents are covered during care for privacy and prevent them from feeling cold. CNA 4 stated when a resident develops goose bumps or shiver, it indicated the resident was uncomfortable, which she had to stop the care, and cover the resident with a blanket. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 5 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE c. A review of the admission records indicated Resident 354 was admitted to the facility on 6/27/19 with diagnoses not limited to traumatic intracranial subarachnoid, and subdural hemorrhage (brain bleed). A review of the history and physical (H&P), dated 6/27/19, indicated Resident 354 was unresponsive on neurological (a branch of medicine concerned especially with the structure, function, and diseases of the nervous system) assessment. During an observation on 7/02/19 at 7:45 a.m., Resident 354 was observed in bed not covered, and naked. The privacy curtains and door were observed open while CNA 1 performed Resident 354's bed bath. CNA 1 stated "no, I am not supposed to attend to a resident with privacy curtains opened." During the observation, registered nurse (RN 9) stated to CNA 1, "To always make sure the privacy curtains were completely closed when attending to residents," to protect their dignity and self-esteem. A review of the facility's policy titled "Resident Rights," dated 5/2017, indicated all residents have rights guaranteed to them under Federal and State law. The rights are not limited to privacy and, even though a resident is determined to be incompetent, should be able to assert these rights.

F578 SS=E Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 07/17/2019 §483.10(c)(6) The right to request, refuse, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 6 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 7 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview, and record review, the facility failed to formulate an advance directive or provide written instructions on how to complete one, and follow up on the decisions as required per the standard of care and facility policy for three of 8 sampled residents (35, 70, 82). This deficient practice could potentially result in the violation of Resident 35, 70, 82's right to choose or withhold treatment. Findings: During an interview with the Social Worker (SW) on 6/27/19 at 3:15 pm, when asked how the facility implemented advanced directives for the residents and where that information was located, SW replied, "the POLST and advanced directives are in the record." The SW stated "Admissions (usually at the affiliated hospital) collects the information, and nursing or social services follows up." During the interview SW stated he had, "No system for follow up for missing advance directives." SW stated he, "Would look for notes that he or nursing had followed up on incomplete advance directives." He then printed and returned a copy of the admissions package, optional (upon request) Advance Directive Toolkit, and any advance directives or follow up notes for the 8 residents. a. During a review of Resident 35's clinical records indicated the resident was originally admitted 5/12/19. Resident 35's diagnoses included a spinal cord stroke (impaired blood flow to spine) that resulted in quadriplegia (unable to move arms and legs), chronic respiratory failure (unable to breathe FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 8 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE independently), tracheostomy (tube in neck to breathe with ventilator - machine to breathe), gastrostomy (tube in stomach for feeding), foley catheter (tube to bladder for urine), Ogilvie's Syndrome (false bowel obstruction), sepsis (body wide infection), and aphasia (unable to speak). A review of Resident 35's face sheet showed the resident was responsible for himself. A medical record review of his 5/14/19 history and physical showed that "advance directives were discussed", but the record gave no details. The record showed conflicting instructions. The one record indicated, "No Code, see prior hospital admission." However, there was a new 5/8/19 order for a full code without explanation. There was no no power of attorney ( a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter) received, there are no advance directives formulated, and no follow up notes. b. A medical record review of Resident 70 showed the resident was originally admitted 8/6/18. Resident 70's diagnoses included quadriplegia (unable to move arms and legs), persistent vegetative state (unresponsive), chronic respiratory failure (unable to breathe independently), a tracheostomy (tube in neck to breathe with ventilator), a gastrostomy (tube in stomach for feeding), and pressure ulcer (bedsore.) A medical record review of Resident 70's history and physical, dated 6/11/19 indicated the resident had anoxic encephalopathy (brain injury from lack of oxygen). Resident 70 had a distant history of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) with multiple suicide attempts. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 9 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 70's face sheet indicated the emergency contact was a designated family member. A review of physician order dated 7/1/19 indicated the resident was full code, since admission dated 8/6/18. A review of his Physician Order for Life Sustaining Treatment ([POLST] an approach to improving end-of-life care in the United States, encouraging providers to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis) indicated the resident was full code. However, Resident 70's or the designated family member had not formulated an advance directives. There was no notes of any attempts to discuss or obtain an advance directive for Resident 70, with legal representative, or conservator, and or follow up. c. A medical record review of Resident 82 showed the resident was originally admitted from another facility 1/19/19 to the affiliated hospital due to sepsis (body wide infection) and encephalopathy (brain disease,) & transferred to subacute 5/31/19. A medical record review of Resident 82's cumulative diagnoses included chronic respiratory failure (unable to breathe) and dependent on a ventilator (machine for breathing) through a tracheostomy (tube in throat) to breathe, cancer of the throat and lung with multiple metastases (cancer spread throughout lungs), chronic lung disease, malnutrition with a gastrostomy (tube to stomach for feeding), kidney disease, alcoholic cirrhosis with ascites (liver disease with fluid accumulation in abdomen). A review of Resident 82's hospital admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 10 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE history and physical indicated the resident was seen by the oncologist (cancer doctor) to treat the cancer as "comfort care only", i.e., no treatment, and "patient is aware & does not want aggressive measures." A review of Resident 82's face sheet indicated two family members were listed as primary contacts. A medical record review of Resident 82's physician orders dated 7/19/19 indicated the resident was full code, which was originally orders on 1/19/19. A review of Resident 82's POLST form indicated the resident was full code and had a legally recognized decision maker, but there was no documentation regarding this person, a POA (power of attorney) any advance directives, or follow up. A review of the policy titled, "Advance Directives" retrieved on 6/27/19, indicated that it is the policy to support the patients' rights to participate in health care decision-making and ensure those wishes are followed if they become incapacitated. Adults will be asked if they have an advanced directive or would like information on formulating one at the time of registration. A patient presenting with an advanced directive will have it honored at the point of receipt and validation by staff and physician. Surrogate decision makers are individuals to whom the providers may look to for decisions if the patient is incapacitated. The Patient Self-Determination Act is the federal law requiring hospitals to provide information on the right to formulate advanced directives concerning health care decisions to all adult inpatients. Information on advanced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 11 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE directives is available on the Intranet and can be provided to the patient upon request. All inpatients will be given specific information concerning advance directives. Conservators can make the same decisions as any other surrogate decision-maker. A POLST is not an advance directive. Under the Procedure - it indicated registration will ask family if they have or would like information on advance directives. They will enter the choice into the record. Upon request, they may provide a copy of the advance health care directive form. There is no documentation if a copy of the form was requested and provided to the patient. At any re-admission, patient will be asked if advance directive is still in effect or if they would like to complete an advance directive. Nursing will review the advance directive during the initial assessment and document it in the record. If there is none, nursing will become familiar with patient's designated agent and advocate that provisions will be honored. If there is a directive that has not been provided, staff will again request a copy for the record. Upon transfer to subacute, nursing will ensure that directive information accompanies the patient, but agent designations & oral requests do not carry over and must be documented again. A review of the resident handout titled, "Advance Directive - California" shows a 9page book that outlined five steps to individualize the form and sign it for submission as an advance directive.

F658 SS=E Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 08/16/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 12 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the facility failed to ensure the nursing staff met professional standards of quality and competency, for proper medication administration techniques for two of 4 nurses observed. During a medication administration two of 4 nurses who were observed administering medications via the residents' gastrostomy tubes ([G-tube] a tube inserted through the abdomen that delivers nutrition directly to the stomach) out of seventeen (17) total nurses in the facility. This deficient practice had the potential for harm to the residents due to the risk of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses as a result of mixing together different medications intended for administration through the G-tube without flushing between medication administrations. Findings: a. During an observation on 6/27/19 at 8:36 a.m., during the morning medication administration (medication pass) for Resident 17 at Station 1 Medication Cart 17, the licensed vocational nurse (LVN 2) administered ten (10) medications through the G-tube. During the pre-flush of 60 ml of water into the syringe barrel, LVN 2 poured one medication after another into the syringe barrel, mixing the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 13 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications together, filling the syringe barrel as the medications drained into the G-tube, with no water flushes between each medication administrations. The color of the mixture of the medications changed as the individual colors of the added medications were mixed together in the syringe barrel. The medications poured into the syringe barrel were Colace (laxative for constipation), Claritin (hay fever medication), Keppra (seizure treatment), Sucralfate (ulcer medication), Norvasc (high blood pressure medication), Multivitamins (dietary supplement), Vitamin D3 (treatment for low calcium in bones), Baclofen (muscle spasm medication), Robinul (treatment of ulcers), and Cozaar (high blood pressure medication), in that order. On the same day at 8:37 a.m., LVN 2 then poured water into each of the ten individual medication cups, and rapidly poured all the rinse water into the syringe barrel as it drained into the G-tube, exceeding 60 ml capacity of syringe barrel. At 8:39 a.m., LVN 2 then administered the post-flush of 60 ml of water into the syringe barrel. b. During an observation on 6/27/19 at 10:18 a.m., of the morning medication pass for Resident 33, at Station 1 Medication Cart 17, the licensed vocational nurse (LVN 3) administered five (5) medications through the G-tube. Beginning with the pre-flush of 60 ml of water into the syringe barrel, LVN proceeded to administer the medications Baclofen, Vitamin D3, Aspirin (blood clot prevention medication), Claritin, and Zantac (ulcer medication). LVN 3 administered two out of the five medications, Vitamin D3 and Aspirin, without water flushes after each administration and before the next medication administration. At the end, LVN 3 administered the post-flush of 60 ml of water into the syringe barrel. During an interview on 6/28/19, at 9:54 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 14 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the registered nurse (RN), and the Nursing Manager (RN 1), regarding what she looked for during her audits of the licensed nurses' knowledge of the medication administration process for residents with G-tubes, stated, "60 cc (volume in cubic centimeters, also known as milliliters, ml), if fluid restricted they may have a different (physician) order, they (licensed nurses) pour the medications one at a time, in between [medications] they have to rinse the medication cup with 5 to 15 cc of water. After that, 60 cc of water to make sure, post-flush, and they document". During a record review, on 6/28/19 at 10:16 a.m., of LVN 2's competency assessment, titled, "Medication Administration in EPIC (facility's computer program), dated 4/4/17, indicated, for "Follow Up Assessment" assessment categories of, "Follows policy and procedures in administering medications through enteral tubes (including G-tube)" and, "Checks placement and residual, flushes tube with 60 ml of water before and after medication administration." LVN 2 received a "Level of Proficiency" score of "4", on a scale of 1 to 4, defined as, "Competent, performs independently and able to assess the competency of others". The assessment did not specifically indicate the process of administering a water rinse or flush in-between medications during G-tube administration. During a record review on 6/28/19 at 10:16 a.m., of LVN 3's competency assessment, titled, "Medication Administration in EPIC, dated 4/3/17, indicated, for "Follow Up Assessment" assessment categories of, "Follows policy and procedures in administering medications through enteral tubes (including Gtube)" and, "Checks placement and residual, flushes tube with 60 ml of water before and after medication administration." LVN 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 15 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE received a "Level of Proficiency" score of "4", on a scale of 1 to 4, defined as, "Competent, performs independently and able to assess the competency of others". The assessment did not specifically indicate the process of administering a water rinse or flush in-between medications during G-tube administration. During an interview, on 7/1/19 at 10:03 a.m., RN 1, regarding if the two licensed nurses were meeting nursing professional standards of quality, stated, "When they don't follow procedures and standards, they are not following the professional nursing standards. They must follow the policy we have." A review of the facility's policy and procedures titled, "Administration of Medication via Nasogastric Tube or Gastrostomy Tube (Gtube)", implementation date March 1991, indicated, "Procedure ...administer one medication at a time via syringe, and rinse the medication cup with 5 to 15 cc." A review of the facility's policy and procedures, titled, "Medication Management", last revised on 6/2019", indicated, "Medication Administration ...The following individuals are authorized to access and administer medications to patients in the facility in accordance with the scope of the licensure after appropriate competency validation ....Licensed Nurses (RN, LVN) ...Employee competency in medication handling and administration is evaluated and documented during the hospital orientation period and as appropriate to ensure patient safety and compliance with medication management standards. A review of the facility's policy and procedures titled, "Medication Management", last revised on 6/2019", indicated, "Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 16 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Administration Procedures ...for specific administration technique (e.g ....feeding tube ...) refer to Lippincott Procedures". A review of the facility's reference titled, "Lippincott Procedures", revised August 17, 2018, indicated, "Implementation ...after verifying proper tube placement, flush the tube with at least 15 ml of purified water ... Clinical alert: Don't mix together different medications intended for administration through the G-tube because of the risk of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses ...administer the medication using a clean enteral syringe ...flush the G-tube again with at least 15 ml of purified water, taking into consideration the patient's fluid volume status. Repeat the procedure for each additional prescribed medication. Flush the G-tube one final time with at least 15 ml of purified water ...Special Considerations ...keep in mind that administering medications through the enteral route can pose risks because most medications given this way weren't originally formulated to be administered directly into the GI tract. If the patient's G-tube becomes clogged, flush the tube with water. If flushing with water is unsuccessful, notify the practitioner; the practitioner my [may] consider using pancreatic enzyme solution, an enzymatic declogging kit, or a mechanical declogging device before exchanging the tube for a new one ...Complications ...instilling the medication too quickly or with too much fluid can cause nausea and vomiting. Tube occlusion (blockage) can result from improper administration technique ...through a gastrostomy tube. Adverse medication events can result from inappropriately crushing or combining medications."

F677 ADL Care Provided for Dependent Residents FORM CMS-2567(02-99) Previous Versions Obsolete

F677 Event ID: JOPE11 07/17/2019 Facility ID: CA930000436 If continuation sheet 17 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.24(a)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record reviews, the facility failed to ensure a complete bed bath was given to one of 23 sampled residents (1). The deficient practice had the potential to result in Resident 1 having body odor, skin breakdown and infections. Findings: A review of Resident 1's admission records indicated she was admitted to the facility on June 18, 2019 with diagnoses that included respiratory failure (blood does not have enough oxygen or has too much carbon dioxide). A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May 13, 2019 indicated Resident 1 was totally dependent on staff for bathing, hygiene, and was incontinent (no control) of bowel and bladder functions. On July 5, 2019 at 11:15 a.m., Resident 1 was observed during a bed bath given by Certified Nursing Assistant (CNA 30) the following was observed: 1. Did not wash chest, legs or feet. 2. No change gloves after wiping buttocks, then FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 18 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE continued turning resident to clean the vaginal area. On July 5, 2019 at 11:15 a.m., in an interview with CNA 30 about Resident 1, stated "only wash resident a little bit and change linen." A review of the facility's policy and procedure revised dated November 2018 titled "Bath and/or Shower" indicated the following: 1. It is the policy pf Providence Little Company of Mary Sub Acute Care center to ensure each resident will receive a bed bath or shower a designated. 2. Assist with bathing as needed, making sure lower extremities and feet are cleansed thoroughly with soap and water.

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 07/17/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 19 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the facility failed to ensure that: 1. Nursing staff did not combine 10 medications and give them all at one time via gastrostomy tube ([G-tube] a tube inserted through the abdomen that delivers nutrition directly to the stomach) without water flush (rinse) after each medication, for one of 4 residents observed during the morning medication administration (medication pass), and, 2. Nursing staff did not administer two medications via G-tube without a water flush after each medication, for one of four 4 residents observed during the morning medication administration (medication pass). Two of one 109 total residents were observed at the facility, the majority who had G-tube, corresponding to 2 nurses observed during medication pass from two medication carts, out of 17 total licensed nurses, who simultaneously administered the morning medications from seventeen medication carts during the morning medication pass. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 20 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This deficient practice had the potential for harm to the residents due to receiving less than the optimal prescribed doses of medications due to potential interactions among the combined medications. Findings: a. During an observation on 6/27/19 at 8:02 a.m., of the morning medication pass for Resident 17 at Station 1 Medication Cart 17, the licensed vocational nurse (LVN 2) administered 10 medications through a G-tube. The medications administered were: (1) Levetiracetam (Keppra, medication indicated as adjunctive therapy for the treatment of epileptic seizures) Oral Solution 500 milligram (mg) per/5 milliliter (ml) (concentration of strength in milligrams per volume in milliliters), 7.5 ml or 750 mg dose; (2) Docusate (Colace, medication used to relieve constipation) 100 mg/10 ml Oral Solution, 20 ml volume or 200 mg dose; (3) Amlodipine (Norvasc, medication used to treat high blood pressure) 5 mg Tablet, 1 tablet; (4) Loraditine (Claritin, medication that temporarily relieves the symptoms of runny nose, itchy, watery eyes, sneezing, itching of nose and throat due to hay fever or other upper respiratory allergies) 5 mg/5 ml Oral Solution, 10 ml or 10 mg dose; (5) Sucralfate (Carafate, medication used to treat ulcers) 1 gm (strength in grams) Tablet, 1 tablet; (6) Baclofen (Lioresal, medication used in the treatment of muscle spasms) 20 mg Tablet, 1 tablet; (7) Multivitamin Chewable Tablet, 1 tablet; (8) Glycopyrrolate (Robinul. medication used as adjunct therapy in the treatment of peptic ulcer) 1 mg Tablet, 1 tablet; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 21 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (9) Vitamin D3 (Cholecalciferol, dietary supplement essential for calcium absorption for healthy bones) 2000 IU (strength in International Units) Tablet, 1 tablet; (10) Losartan (Cozaar, medication indicated for high blood pressure) 25 mg Tablet, ½ tablet or 12.5 mg dose. The tablet dosage forms were individually crushed and mixed with approximately 10 ml of water into separate medication cups. During an observation, on 6/27/19 at 8:36 p.m., LVN 2 administered the pre-flush of 60 ml of water into the syringe barrel, then simultaneously poured one medication after another into the syringe barrel, filling it at the same time as the medications slowly drained into the G-tube. The medications were mixed together, with no water rinses between medications. The color of the mixture of the medications changed as the individual colors of the added medications were mixed together in the syringe barrel. The medications poured into the syringe barrel were Colace, Claritin, Keppra, Sucralfate, Norvasc, Multivitamins, Vitamin D3, Baclofen, Robinul, and Cozaar, in that order. During an interview on 6/27/19 at 8:37 a.m., LVN 2 regarding her medication administration technique, stated, "I gave everything, I will rinse it (meds cups) now so I can get all the (residual) medicine." During an observation, on 6/27/19 at 8:37 a.m., LVN 2 then poured water into each of the ten individual medication cups, and rapidly poured all the rinse water into the syringe barrel as it drained into the G-tube, exceeding 60 ml capacity of syringe barrel. During an observation, on 6/27/19, at 8:39 a.m., LVN 2 then administered the post-flush of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 22 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 60 ml of water into the syringe barrel. During an interview, on 6/27/19 at 8:46 a.m., LVN 2, regarding if Resident 17 was fluid restricted, stated, "No, sir". Regarding the practice of rinsing between the medication administrations (to avoid potential interactions), LVN 2 stated, "You can put them in one at a time, so they are 'not' mixed together." During an interview, on 6/28/19 at 9:54 a.m., the RN (registered nurse) Nurse Manager (RN 1), regarding what she looked for during audits of licensed nurses' medication administration process, stated, "60 cc (volume in cubic centimeters, same as ml, volume in milliliters) of water initially (pre-flush), if fluid restricted they may have a different [physician] order, they [licensed nurses] pour the medication one at a time, in between [medications] they have to rinse the medication cup, 5 to 15 cc of water. After that, 60 cc of water to make sure, post flush, and they document." b. During an observation, on 6/27/19 at 10:18 a.m., of the morning medication pass for Resident 33, at Station 1 Medication Cart 17, LVN 3 administered 5 medications through the G-tube. The medications administered were: (1) Ranitidine (Zantac, a medication indicated for the treatment of ulcers) 150 mg/10 ml Oral Solution, 20 ml or 300 mg dose; (2) Loraditine (Claritin, medication that temporarily relieves the symptoms of runny nose, itchy, watery eyes, sneezing, itching of nose and throat due to hay fever or other upper respiratory allergies) 5 mg/5 ml Oral Solution, 10 ml or 10 mg dose; (3) Vitamin D3 (Cholecalciferol, dietary supplement essential for calcium absorption for healthy bones) 2000 IU (strength in International Units) Tablet, 1 tablet; (4) Aspirin (medication indicated for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 23 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prevention of blood clots that can lower the risk for heart attacks or clot-related strokes) 81 mg Tablet, 1 tablet; and, (5) Baclofen (Lioresal, medication indicated for the treatment of muscle spasms) 10 mg Tablet, 1 tablet. The tablet dosage forms were individually crushed and mixed with 10 ml of water in separate medication cups. LVN 2 administered the pre-flush of 60 ml of water into the syringe barrel, then proceeded to administer the medications Baclofen, Vitamin D3, Aspirin, Claritin, and Zantac. LVN 3 administered two out of the five medications, Vitamin D3 and Aspirin, without water flushes after each of them. Then, LVN 3 administered the post-flush of 60 ml of water into the syringe barrel. During an interview on 6/27/19, at 10:57 a.m., LVN 3, regarding if Resident 33 was fluid restricted, stated, "No, she is not". Regarding flushing with water after each medication (to avoid potential interactions), stated, "I already had the 10 to 15 ml to the medications (Vitamin D3 and Aspirin)." Regarding if he considered the addition of 10 to 15 ml of water to dissolve the Vitamin D3 and Aspirin, respectively, as the flushes, LVN replied "Mmm. Hmm (yes)". During an interview, on 7/1/19 at 10:03 a.m., the RN Nurse Manager (RN 1), regarding if the two licensed nurses (LVN 2 and LVN 3) were meeting nursing professional standards of quality, stated, "When they don't follow procedures and standards, they are not following the professional nursing standards. They must follow the policy we have." A review of the facility's policy and procedures, titled, "Administration of Medication via Nasogastric Tube or Gastrostomy Tube (Gtube)", implementation date March 1991, indicated, "Procedure ...administer one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 24 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication at a time via syringe, and rinse the medication cup with 5 to 15 cc (volume in cubic centimeters, also known as milliliters, ml)." A review of the facility's policy and procedures, titled, "Medication Management", last revised 6/2019, indicated, "Medication Administration Procedures ...for specific administration technique (e.g ....feeding tube ...) refer to Lippincott Procedures". A review of the facility's reference, titled, "Lippincott Procedures", revised August 17, 2018, indicated, "Implementation ...after verifying proper tube placement, flush the tube with at least 15 ml of purified water ... Clinical alert: Don't mix together different medications intended for administration through the G-tube because of the risk of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses ...administer the medication using a clean enteral syringe ...flush the G-tube again with at least 15 ml of purified water, taking into consideration the patient's fluid volume status. Repeat the procedure for each additional prescribed medication. Flush the G-tube one final time with at least 15 ml of purified water ...Special Considerations ...keep in mind that administering medications through the enteral route can pose risks because most medications given this way weren't originally formulated to be administered directly into the GI tract. If the patient's G-tube becomes clogged, flush the tube with water. If flushing with water is unsuccessful, notify the practitioner; the practitioner my [may] consider using pancreatic enzyme solution, an enzymatic declogging kit, or a mechanical declogging device before exchanging the tube for a new one ...Complications ...instilling the medication too quickly or with too much fluid can cause nausea and vomiting. Tube occlusion can result from improper FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 25 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administration technique ...through a gastrostomy tube. Adverse medication events can result from inappropriately crushing or combining medications."

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 08/16/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 26 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure three of 3 sampled residents did not receive unnecessary medications (24, 90, 19). Resident 24 did not have an appropriate indication for the use of Zoloft (medication for abnormal mood) given for depression sad mood manifested by sad facial expression, Resident 90, there was no attempt at replying to pharmacist medication regimen review (a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy) to reduce duplicate therapy that included Benadryl (allergy medication that may produce sleepiness and Loratidine (allergy medication) given for the same indication of hypersecretions (excessive production of a bodily secretion) without an indication for its use, and, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 27 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 19, was receiving Celexa for depression manifested by sadness, that was inadequate indication and did not identify a specific behavior for its use. These deficient practices resulted in duplication, and inappropriate indication for Residents 24, 90, and 19's psychotropic medications (a substance affecting mental activity, behavior, or perception, as a moodaltering drug). Findings: a. A review of the admission records indicated Resident 24 was admitted to the facility on 1/19/19 with diagnoses not limited to depression (abnormal mood disorder). A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/19/19, indicated Resident 24 had no cognitive (ability to learn, remember, understand and make decisions) impairment. During medication record review on 7/03/19 at 10:40 a.m., registered nurse (RN 10) verified and stated Resident 24 was on Zoloft 25 milligrams (mg) orally (PO) nightly for depression sad mood manifested by (M/B) sad facial expression. During an interview on 7/03/19 at 11:32 a.m., pharmacist (Pharm 1) about Resident 24 receiving Zoloft, stated facial sadness was not an appropriate indication to prescribe psychotropic (a substance affecting mental activity, behavior, or perception, as a moodaltering drug) medications for. b. A review of the admission records indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 28 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 90 was admitted to the facility on 5/14/19, with diagnoses not limited to respiratory failure, tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and increased tracheal (wind pipe, airway). A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/20/19, indicated Resident 90 had moderate cognitive impairment. During observations of 6/27/19 at 9:00 a.m. and 10:17 a.m., Resident 90 was observed in bed asleep. There was no excessive secretions noted. During observations on 6/28/19 at 7:14 a.m., 10:14 a.m. and 10:38 a.m., Resident 90 was observed in bed asleep. There was no excessive secretions noted. During medication record review on 6/27/19 at 2:11 p.m., Pharm 3 verified that Resident 90 was on Benadryl (allergy medication that may produce sleepiness) 25 mg nightly for hypersecretory (excessive production of a bodily secretion), and Loratidine (allergy medication) 10 mg daily for hypersecretions. During a concurrent interview, Pharm 3 was not able to explain the reason why Resident 90 was on two medications, Benadryl, and Loratidine, for the same purpose for hypersecretory. During an interview on 7/03/19 at 11:07 a.m., Pharm 1 "I have not requested the physician to review Benadryl and Claritin (Loratidine) order, nor conduct medication regimen review (MRR)" for Resident 90. Pharm 1 stated Resident 90's physician always declined MRR recommendation for Benadryl and Loratidine, and did not utilize the chain of command for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 29 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physician who do not positively respond to pharmacists medication recommendations. Pharm 1 stated "This is duplicate therapy." b. A review of the admission records indicated Resident 19 was admitted to the facility on June 27, 2017, with a diagnosis including respiratory failure (blood does not have enough oxygen or has too much carbon dioxide). The Minimum Data Set assessment (MDS), a standardized assessment and care screening tool, dated June 17, 2019 indicated Resident 19 sometimes had the ability to make self be understood, and sometimes had the ability to understand others. A record review of physician order dated June 23, 2019 indicate Resident 19 was receiving Celexa 20 milligrams (mg) daily for depression manifested by sadness via gastrostomy tube ([G-tube] a tube inserted through the abdomen that delivers nutrition directly to the stomach). During an interview Director on Nursing (DON) on July 3, 2019 at 10:00 a.m., acknowledged she was not aware that Resident 19's physician order for Celexa 20 mg daily manifested for sadness via G-tube was an inadequate indication and did not identify a specific behavior for its use. A review of the facility's revised policy and procedure, revised date May 2016, titled "Psychoactive Drug Monitoring" indicate the following: 1. Each drug shall have the dosage, frequency, indication and behavior monitored. 2. Specific condition/behavior concern.

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1) FORM CMS-2567(02-99) Previous Versions Obsolete

F759 Event ID: JOPE11 08/16/2019 Facility ID: CA930000436 If continuation sheet 30 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate of less than 5 percent (%), due to 12 medication administration errors involving two of four 4 residents observed during medication administration (med pass). This deficient practice of 12 medication administration error rate out of 29 opportunities for error, resulted in a medication administration error rate of 41 %, exceeding the 5 % threshold. Findings: During an observation on 6/27/19 starting at 8:02 a.m., of the morning medication pass for Resident 17 at Station 1 Medication Cart 17, the licensed vocational nurse (LVN 2) administered ten (10) medications through gastrostomy tube ([G-tube] a tube inserted in to the stomach for nutrition and hydration). LVN 2 administered the pre-flush of 60 ml of water into the syringe barrel, then simultaneously poured one medication after another into the syringe barrel, filling it at the same time as the medications slowly drained into the G-tube. The medications were mixed together, with no water rinses between medications. The color of the mixture of the medications changed as the individual colors of the added medications were mixed together in the syringe barrel. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 31 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications poured into the syringe barrel were Colace, Claritin, Keppra, Sucralfate, Norvasc, Multivitamins, Vitamin D3, Baclofen, Robinul, and Cozaar, in that order. During an observation, on 6/27/19 at 10:18 a.m., of the morning medication pass for Resident 33, at Station 1 Medication Cart 17, the licensed vocational nurse (LVN 3) administered five (5) medications through the G-tube. LVN 3 administered the pre-flush of 60 ml of water into the syringe barrel, then proceeded to administer the medications Baclofen, Vitamin D3, Aspirin, Claritin, and Zantac. LVN 3 administered two out of the five medications, Vitamin D3 and Aspirin, without water flushes after each of them. Then, LVN 3 administered the post-flush of 60 ml of water into the syringe barrel. There was ten medications combined in the syringe barrel and administered all at once via the G-tube, without water flushes between the medications, and two medications were administered via G-tube without water flushes inbetween the medications.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 07/17/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 32 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the facility failed to ensure that room thermometers and room temperature monitoring records were in place, and to ensure that storage of medications were within the specified manufacturers' temperature ranges, in two (2) out of three (3) medication storage rooms. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. Findings: a. During an observation, on 6/28/19 at 12:54 p.m., in the LUMS (facility's name for Central Supply) Room, there was no room thermometer and no room temperature monitoring log. The room contained over-thecounter house supply external creams and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 33 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ointments stored in four (4) treatment carts, with storage temperature information on the manufacturer's labels, and bottles of irrigation solutions stored on the shelves, with storage temperature information on the manufacturer's labels. During an interview, on 6/28/19 at 1:10 p.m., the licensed vocational nurse (LVN 8), after reviewing the labeled manufacturer's storage temperature ranges for the external medications and irrigation solutions, stated, "No, there's no thermometer in this room." Regarding a room temperature monitoring log, LVN 8 stated, "No, not on this room". b. During an observation, on 6/28/19 at 1:54 p.m., in the Station 2 Medication Room, there was no room thermometer and no room temperature monitoring log. The room contained the "Pyxis" brand Automated Drug Dispensing System (a secure metal cabinet containing medications, utilizing a mechanical system that performs operations or activities, other than compounding or administration, relative to the storage, dispensing, or distribution of drugs), with the medications stored under the temperature conditions of the enclosed medication room. During an interview, on 6/28/19 at 1:55 p.m., the registered nurse (RN 2), regarding a room thermometer, stated, "We don't have a room thermometer in here." A review of the facility's pharmacy policy and procedures, titled, "Storage of Medications Hospitalwide", revised January 2019, indicated, "Policy ...all medications are stored in designated areas which are sufficient to ensure proper ...temperature ..." A review of the facility's pharmacy policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 34 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE procedures, titled, "Beyond Use Dating", revised August 2018, indicated, "Storage Temperatures ...USP <797> (Chapter 797 "Pharmaceutical Compounding - Sterile Preparations," in the USP National Formulary. It is the first set of enforceable sterile compounding standards issued by the United States Pharmacopeia [USP]) definitions of storage temperatures will be followed unless otherwise specified by manufacturers and other reliable sources ...Controlled room temperature (20 - 25 degrees C)(Celsius, a metric unit of temperature measure) 68 - 77 degrees F (Fahrenheit)."

F812 SS=D Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 07/17/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 35 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, and interview, the facility failed to distribute, store, and serve foods under sanitary conditions. These deficient practices had the potential for the food to become contaminated with harmful microorganisms causing foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), to the susceptible residents. Findings: a. During the initial tour of the kitchen and inspection of the facility's food preparation area was conducted on June 27, 2019 at 7:31 a.m., the following was observed: 1. Two gallons of Roux (thickening agent for soups and sauces) stored uncovered in oven (Southbend eight burners). 2. Two - 1 gallon containers with uncovered used/old grease. 3. Two - 2 gallon containers with uncovered used/old grease. 4. Southbend Eight burner stove top grease build up and debris. 5. Montague 12 burner stove top grease build up and debris. 6. Fryer grease build up and debris. 7. MagiKitch'n Gas Broiler build up grease build up and debris. During an interview with the Dietary Cook (DC) on June 27, 2019 at 7:31 a.m., he acknowledged storing the uncovered Roux in the oven and stated the Southbend eight burner's oven did not work. During an interview with Dietary Supervisor on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 36 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE June 27, 2019 at 7:31 a.m stated, the Roux should be covered and not stored in oven. The Dietary Supervisor also acknowledged there was grease build up and debris on cooking appliances. b. During initial tour on June 27, 2019 at 8:10 a.m., the Registered Dietician (RD) was observed walking into the kitchen, went to the steam table, touched the utensils and placed food inside a white foam food take out container, without first washing her hands with soap and water. During an interview on July 2, 2019 at 11:36 a.m., RD acknowledged not washing her hands upon entering the kitchen, and before serving food by touching the utensils. c. During the initial tour on June 27, 2019 at 8:25 a.m., the Dietary Aide (DA) was observed walking into the kitchen with a cup in hand, walked over to the coffee machine without washing his hands or placing a hairnet on. During an interview on June 27, 2019 at 8:25 a.m., DA acknowledged not washing his hands, and not placing hair net on upon entering the kitchen. During an interview with Dietary Supervisor on June 27, 2019 at 8:30 a.m., stated "everyone should wash hands and place hair net on when coming into the kitchen". The facility's policy with a revised date January 12, 2014, titled "Sanitation of Food Services Equipment and Facilities" indicated the following: 1. Ranges and Hood after each use tops of grills are scraped to remove all loose soil from surface. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 37 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F867 QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/17/2019 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to identify, using the Quality Assurance and Performance Improvement ([QAPI] the coordinated application of two mutually-reinforcing aspects of a quality management system, taking a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality, while involving residents and families, and all nursing home caregivers in practical, and creative problem solving) by reviewing service and outcomes, and systems throughout the facility for assuring that care was maintained at acceptable levels in relation to those standards, in order to correct implement corrective actions to decrease the risks associated with not adhering to standards of infection control practices. This deficient practice had the potential to result in 35 of 41 residents (73, 19, 96, 14, 1, 11, 75, 54, 86, 59, 7, 15, 87, 41, 84, 32, 64, 21, 53, 27, 35, 38, 101, 3, 6, 28, 48, 2, 10, 66, 354, 51, 97, 47, 205) with respiratory infections who were on contact isolation, and six of 41 (Residents 4, 79, 91, 92, 62, and 82) who were not on contact isolation, with infections not limited to antibiotic resistant Carbapenem Resistant Pseudomonas Aeruginosa ([CRPA] a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 38 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE common bacteria that causes infection). Findings: a. During a QAPI review interviews on 7/3/19 at 2:16 p.m., Director of Nursing (DON) and Chief Executive Officer (CEO) stated the facility had not identified current trend of widespread drug resistant respiratory infection, such as CRPA. CEO stated, "now that we know, we will work on it. Since CRPA is an emerging organism, we will not wait for the quarterly QAPI meeting to take action." b. During an Antibiotic Stewardship interview on 7/3/19 at 7:54 a.m., Infection Preventionists (IP) 1, and 2 stated preventive infection control practices included hand hygiene (applying an alcohol-based handrub to the surface of hands or washing hands with the use of a water and soap or a soap solution, either nonantimicrobial or antimicrobial) before and after resident care, before and after putting and removing gloves, respiratory hygiene precaution (cough and sneeze in the elbow, then to implement hand hygiene), disinfecting (the process of cleaning something, especially with a chemical, in order to destroy bacteria) medical equipment, and waste disposal. During interview IP 1 stated, "Housekeeping and all staff are expected to adhere to infection control policies, and "secret shoppers" (staff assigned to observe infection prevention compliance) monitored to ensure staff were compliant with hand hygiene, and use of personal protective equipment (protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection). IPs 1, and 2 stated the facility had a documented procedure for disinfecting equipment but no monitoring was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 39 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE done to ensure medical equipment, and shared medical devices were sanitized before, and after residents' use. IPs 1, and 2 were not able to state who, how, when the equipment, including the Workstation on Wheels ([WOW] a portable computer mounted on a wheeled cart that has a keyboard, mouse and power cord), and pulse oximeters (a device that measures the saturation of oxygen carried in the blood), were sanitized. During an interview on 7/5/19 at 9:20 a.m., IP 1 stated the residents' infections were reported to the Quality Assessment and Assurance ([QAA] the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards) committee as part of the QAPI program every three months during QAA/QAPI meeting. IP 1 stated the facility did not trend the risks associated with poor infection control practices, specially among the residents who tested positive for specific type of microorganisms. During an interview on 7/5/19 at 11:32 a.m., DON stated the facility utilized staff as 'secret shoppers." However, DON stated the facility did not have a policy and procedure on a job description as to what training they required, and what exactly a secret shoppers did. During an interview on 7/5/19 at 1:57 p.m., LVN 5 stated, she was designated as a secret shopper. LVN 5 stated, "I check nurses, RT, physicians and all staff, to see if they perform hand washing before and after resident's care, and if they are placing the gowns on correctly." LVN 5 stated the IPs told her to check if the employees were performing hand hygiene. LVN 5 verified that IP did not instruct her to monitor how the patient care equipment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 40 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (WOW, medication and treatment carts, shower beds, and shower chairs) were sanitization inbetween the resident care. A review of the facility's document dated 20182019, titled "Quality Assurance and performance Improvement (QAPI) Plan" indicated the facility is to conduct analyses of serious safety events, including but not limited to root cause analyses, intense analysis. These teams are composed of designated individuals in Medical Staff, Risk Management, Quality Improvement, Administration, and care givers as indicated by the event. Individuals participating in these analyses are oriented to the processes.

F880 SS=L Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 07/17/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 41 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 42 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure licensed and non-licensed staff practiced proper infection control measures while providing care to residents on contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment) for 35 of 41 residents (73, 19, 96, 14, 1, 11, 75, 54, 86, 59, 7, 15, 87, 41, 84, 32, 64, 21, 53, 27, 35, 38, 101, 3, 6, 28, 48, 2, 10, 66, 354, 51, 97, 47, 205) with infections who were on contact isolation. The facility had six residents (4, 79, 91, 92, 62, and 82) that were not on contact isolation. According to the facility's document dated 6/28/19 titled, "Resident Census and Conditions of Resident," the facility census was 109 residents. The facility failed to: 1. Ensure staff performed hand hygiene before and after residents' care. 2. Ensure staff sanitized (to free from dirt, germs), shared equipment before and after residents' use. 3. Ensure staff utilized personal protective equipment ([PPE] gowns, gloves, goggles for eye protection, and face masks) as indicated on the sign for 'Contact Isolation' signs posted outside the residents' room. 4. Ensure staff was removing PPE after having contact with a resident, the surrounding environment, medical equipment, and before leaving/exiting the contact isolation rooms. 5. Ensure staff were preventing hands and clothing from touching potentially contaminated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 43 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE environmental surfaces or items. 6. Ensure Environmental Services Staff (EVS 2) did not take the housekeeping cart inside a contact isolation room, and disinfect any supply brought to the rooms, at the end of the cleaning routine. On 7/2/19, the survey team identified an Immediate Jeopardy (IJ) related to lack of proper Infection Control practices and on the same day at 11:51 a.m., in the presence of Director of Nursing (DON) and Chief Executive Officer (CEO), the Survey Team called an IJ due to inadequate Infection Control practices. On 7/2/19 at 11:51 a.m., an Immediate Plan of Action (POA) was received and the corrective actions included the following: 1. Immediate education to all staff on proper infection control practices. 2. All equipment used with multiple residents (portable computer workstations, carts, environmental surfaces, etc.) would undergo disinfection and cleaning. 3. An audit tool was revised to include monitoring disinfection of multi-resident use equipment before and after use of a resident. On 7/3/19 at 2:07 p.m., the Team verified the corrective POA and accepted the POA. On 7/3/19 at 2:10 p.m., the IJ was lifted. Findings: On 6/27/19 at 8:51 a.m., during an interview, DON stated there were 35 residents requiring contact isolation precautions and 19 (1, 7, 10, 14, 15, 19, 35, 38, 41, 47, 51, 52, 66, 73, 86, 87, 97, 101, and 354) of the 35 residents had Carbapenem Resistant Pseudomonas Aeruginosa ([CPRA] a bacteria that causes infection) in sputum (thick mucus which is coughed up from the lungs). The remaining 16 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 44 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents (2, 3, 6, 11, 21, 27, 28, 32, 48, 53, 54, 59, 64, 75, 84, and 95) had different types of infections requiring contact isolation. On 6/27/19 at 9:57 a.m., during an observation, a contact isolation sign was posted outside Room 113 instructing all staff and visitors to perform hand hygiene (a way of cleaning one's hands that substantially reduces potential harmful microorganisms on the hands), wear gown and gloves before entering the room, and clean hands before and after each resident care. During observation, below the contact isolation sign, there was a cart containing PPE to be used when entering the room. A medication cart was observed inside Room 113 and the power cord was plugged in a power outlet inside the bathroom of Room 113. Concurrently, Licensed Vocational Nurse (LVN 6) was observed unplugging the medication cart power cord from the bathroom of Room 113. After leaving Room 113, LVN 6 was observed removing PPE, then sanitized the hands. LVN 6 was observed wheeling the medication cart to Resident 59's room who was on contact isolation. LVN 6 failed to sanitize the Workstation on Wheels ([WOW] a portable computer mounted on a wheeled cart that has a keyboard, mouse and power cord) before taking it in to the Resident 59's room. On 6/27/19 at 10:16 a.m., LVN 6 was observed wearing PPE, wheeling the WOW inside Resident 59's room who was on contact isolation. LVN 6 was observed preparing and administering medication via gastric tube ([GTube] a flexible tube inserted into the stomach to provide nutrition, medication and hydration) for Resident 59. LVN 6 was observed typing on the keyboard and using the mouse with the same gloves used to administer medications. LVN 6 was observed removing potentially contaminated gloves after administering FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 45 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications and with bare hands, pushed the WOW out of Resident 59's room. LVN 6 failed to sanitize the hands, the WOW, keyboard and the mouse. 2. On 6/27/19 at 11:50 a.m., Respiratory Therapist (RT 4) was observed entering Resident 3's room, who was on contact isolation, without wearing PPE. RT 4 did not perform hand hygiene and did not wear PPE before entering Resident 3's room. While in Resident 3's room, RT 4 touched the cool aerosol bottle (part of the oxygen equipment) and Resident 3's tracheostomy tubing (a breathing tube placed into the throat for breathing), with bare hands and then touched her own hair. RT 4 then walked out of Resident 3's room, wheeling the WOW cart without performing hand hygiene, and sanitizing the WOW. RT 4 was observed walking to and punching in a code on a keypad to enter the RT Clinical Supervisor's (RTCS) office. A review of Resident 3's Admission Records (Face Sheet), indicated Resident 3 was admitted to the facility on 3/1/19 with diagnoses including respiratory failure with tracheostomy and diabetes (abnormal blood sugar levels). A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and carescreening tool, dated 3/11/19, indicated Resident 3 had long and short-term memory problems and was severely impaired in cognition (ability to learn, remember and make decisions) for daily decision making. A review of Resident 3's urine test collected on 5/10/19, indicated Resident 3 had Proteus Mirabilis (bacteria transmitted mainly through contact with infected persons or contaminated objects and surfaces) infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 46 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 3's tracheal aspirate (respiratory secretions) test result, dated 5/14/19, indicated Resident 3 had Acinetobacter Baumann (bacterial infection that can be spread through direct contact with surfaces, objects, or the skin of people that are contaminated). On 7/5/19 at 10:57 a.m., during an interview, RT 4 stated, "I am supposed to sanitize the equipment used and change gloves before and after resident's care to prevent spread of infection." 2. On 6/27/19 at 12:08 a.m., LVN 4 was observed inside Resident 92's room without gloves holding a scanner in one hand, touching Resident 92's blanket and arm, and proceeded to scan Resident 92's wristband identification barcode. Then, LVN 4 went outside the room, to the medication cart, proceeded to prepare Resident 92's medications, and went back inside the room to administer medications to Resident 92 without performing hand hygiene. LVN 4 donned (put on) clean gloves, checked Resident 92's nasogastric tube ([NGT] a tube placed into the stomach through the nose for nutrition, hydration and medication) placement and administered the medications. On 6/28/19 at 8:15 a.m., Resident 82 was observed with a tracheostomy tube (a catheter that is inserted into the neck for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen) that was connected to a ventilator (breathing machine). Certified Nurse Assistant (CNA 5) was observed walking through the hallway while wearing gloves and gown. Then, CNA 5 entered Resident 82's room and touched the privacy curtain and Resident 82 in preparation for a bed bath. CNA 6, who was also in Resident 82's room, was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 47 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observed while wearing gloves, emptying Resident 82's urinal (urine container), and touching the privacy curtains with contaminated gloves. CNA 6, after emptying the urinal, did not change the gloves and performing hand hygiene, CNA 6 continued to assist with Resident 82's bed bath. CNA 6 finished assisting with the bed bath, took off the contaminated gloves, washed her hands, left the room, and was observed documenting at Station 2. On the same day at 8:28 a.m., CNA 6 was observed returning to Resident 82's room, wearing gloves from the isolation cart to assist CNA 5 with bed bath. CNA 6 failed to perform hand hygiene before assisting with Resident 82. 4. On 6/28/19 at 8:28 a.m., Resident 205 was in an isolation room. RT 4 was observed wearing gown, gloves, and using a pulse oximeter (a device that measures oxygen in the blood while placed on a finger) with Resident 205. RT 4 proceeded to document on the WOW with the potentially contaminated gloves. RT 4 left the room with the WOW and the pulse oximeter without first sanitizing them. RT 4 then entered Resident 2's room. 5. A review of the Admission Records indicated Resident 2 was admitted on 5/31/19, with diagnoses including tracheostomy. A review of a Respiratory Culture Report, dated 5/8/19 indicated Resident 2 tested positive for Multi Drug Resistant ([MDR] bacteria resistant to multiple antimicrobial drugs) Escherchia Coli (bacteria commonly found in the intestines which causes severe abdominal cramps, bloody diarrhea and vomiting). 6. A review of the Admission Records indicated Resident 1 was admitted to the facility on 5/14/19 with diagnoses not limited to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 48 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE respiratory failure and tracheostomy. A review of the Admission Record indicated Resident 96 was admitted to the facility on 1/5/17 with diagnoses not limited to respiratory failure and tracheostomy. On 6/28/19 at 8:30 a.m., RT 1 was observed using the WOW inside Resident 1's Room, who was on contact isolation. RT 1 was typing wearing gloves used to provide respiratory care. RT 1 proceeded to go into Resident 96's room to provide respiratory care. RT 1 failed to remove the contaminated gloves, perform hand hygiene and sanitize the WOW in between care of Residents 1 and 96. On 7/5/19, at 8:30 a.m., during an interview, RT 1 acknowledged he should have performed hand hygiene (after removing gloves), and sanitized the WOW in between the care of Resident 1, and 96's care. 7. A review of the Admission Records indicated Resident 48 was admitted to the facility on 11/16/15 with diagnoses not limited to respiratory failure and tracheostomy. On 6/28/19 at 8:31 a.m., during an observation, and interview, RT 5 was inside Resident 48's room, who was on contact isolation, using the WOW. RT 5 was wearing gloves, mask, and gown and was touching Resident 48's tracheostomy tubing. During observation, RT 5 was typing, touching the computer screen and mouse, while wearing the contaminated gloves. During an interview about not abiding by proper infection control practices, RT 5 stated he just gave Resident 48 a breathing treatment. 8. A review of the Admission Record indicated Resident 19 was admitted 6/27/19 with diagnoses not limited to respiratory failure and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 49 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tracheostomy. On 7/1/19 at 7:50 a.m., Certified Nurse Assistant (CNA 11) was observed going into Resident 19's room, who was on contact isolation, without wearing any PPE to provide morning care. 9. A review of the Admission Records indicated Resident 62 was admitted on 11/26/17 with diagnoses not limited to respiratory failure and tracheostomy. On 7/2/19 at 8:30 a.m., CNA 7, while wearing gloves, was observed providing a bed bath to Resident 62. CNA 7 closed Resident 62's privacy curtain with the potentially contaminated gloves and continued bathing Resident 62. 10. On 7/2/19 at 8:40 a.m., RT 3 was observed outside Resident 19's contact isolation room with the WOW. Then, RT 3 went inside Resident 19's room, touched the privacy curtains with bare hands, and handed over a bottle of nourishment to LVN 7. RT 3 was observed leaving the room and documenting on the WOW. RT 3 failed to donne PPE before entering Resident 19's room, perform hand hygiene after leaving the room, and after using the WOW to document. During an interview on 7/5/19 at 1:28 p.m., RT 3 acknowledged he should have donned PPE before entering Resident 19's contact isolation room, perform hand hygiene and sanitize the WOW before using it. RT 3 stated what she had done, "this is not proper infection control practice." 11. A review of the Admission Records indicated Resident 91 was admitted on 4/20/19 with diagnoses not limited to respiratory failure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 50 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and tracheostomy. On 7/2/19 at 8:45 a.m., RT 6 was observed wearing gloves while administering a breathing treatment to Resident 91. Then, RT 6 used the WOW outside the room to document (touched the keyboard, screen and mouse). RT 6 failed to perform hand hygiene and sanitize the WOW before going to assist Resident 96. 12. A review of the Admission Records indicated Resident 4 was admitted on 3/15/19 with diagnoses not limited to respiratory failure and tracheostomy. On 7/5/19 at 8:05 a.m., during observation, CNA 4 and 8 were preparing Resident 4 for a bed bath, CNA 8 was wearing gloves and was touching Resident 4. With the potentially contaminated gloves, CNA 8 partially closed the privacy curtain, opened the bathroom door, turned on the water faucet, and removed clean linen from Resident 4's drawers. On 7/5/19 at 9:13 a.m., during an interview, CNA 4 stated "We (CNA's 4 and 8) should have washed Resident 4's private parts last because it is not a clean area. 13. A review of the Admission Records indicated Resident 14 was admitted on 6/22/16 for diagnoses not limited to respiratory failure and tracheostomy. On 7/2/19 at 1:10 p.m., RT 2 was observed inside Resident 19's, contact isolation room with the WOW. RT 2 typed information using the keyboard and mouse while wearing potentially contaminated gloves used to provide respiratory care for Resident 19. Then, RT 2 was observed going into Resident 14's contact isolation room. RT 2 failed to remove gloves, perform hand hygiene and sanitize the WOW in between providing care for Residents 19 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 51 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 14. On 7/519 at 1:25 p.m., during an interview, RT 2 acknowledged not removing the contaminated gloves, not washing hands and not sanitizing the WOW before proceeding to provide care for another resident. 14. On 7/3/19 at 8:30 a.m., EVS 2 was observed cleaning Resident Rooms 212, 213, and 214, which were designated as contact isolation rooms. EVS 2 pulled the housekeeping cart half-way into each room. EVS 2 did not sanitize the housekeeping cart between rooms. Concurrently, during an interview, EVS 2 stated she was not aware she needed to sanitize the cart before taking it to another resident room. On 7/3/19, at 2:24 p.m., during an interview, Environmental Services Manager (EVSM) stated when cleaning, the housekeeping cart should remain outside the residents' rooms. A review of the facility's policy titled "Terminal Cleaning," revised on 9/2018 indicated staff should park the cleaning cart outside the doorway to the room to allow easy access to supplies. Before leaving the room at the end of the cleaning routine, staff should wipe supplies with disinfectant. 15. A review of the admission records indicated Resident 79 was admitted on 6/5/19 for diagnoses not limited to respiratory failure and tracheostomy. On 7/5/19 at 8:05 a.m., during a bed bath observation, CNA 4 was observed washing Resident 79's private area and buttocks before washing the legs with the same gloves and soapy water. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 52 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 7/5/19 at 9:13 a.m., CNA 4 stated, "I am supposed to start washing the face followed by hands, armpits, chest, legs and private parts at the end." During an Antibiotic Stewardship interview on 7/3/19 at 7:54 a.m., Infection Preventionists 1 and 2 stated preventive infection control practices included hand hygiene before and after resident care, before and after putting and removing gloves, respiratory hygiene precaution (cough and sneeze in the elbow then hand hygiene), disinfection of medical equipment, and waste disposal. IP 1 stated, "Housekeeping and all staff are expected to adhere to infection control policies, and "Secret Shoppers" (staff assigned to observe infection prevention compliance) monitor to ensure all care providers are compliant with hand hygiene and use of PPE. IPs 1 and 2 stated the facility had a documented procedure for disinfecting equipment but no monitoring was done to ensure medical equipment and shared medical devices were sanitized before and after residents' use. IPs 1 and 2 were not able to state how, who, and when equipment, including the WOW and pulse oximeter, were sanitized. During an interview on 7/5/19 at 9:20 a.m., IP 1 stated residents' infections are reported to the Quality Assessment and Assurance (QAA) committee as part of the Quality Assurance Performance Improvement (QAPI) Program every three months during QAA/QAPI meeting. IP 1 stated the facility did not trend for positive cultured microorganisms. During an interview on 7/5/19 at 11:32 a.m., DON stated the facility did not have a policy and procedure that described what the 'Secret Shoppers' jobs, and training consisted of. During an interview on 7/5/19 at 1:57 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 53 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 5 stated, she was designated as a secret shopper. LVN 5 stated, "I check nurses, RT, physicians and all staff, if they perform hand washing before and after resident's care, and if they are placing the gowns on correctly." LVN 5 stated the IPs told her to check if the employees were performing hand hygiene. LVN 5 verified that IP did not instruct her to monitor equipment (WOW, medication and treatment carts, shower beds, and shower chairs) sanitization in between resident care. A review of the facility's undated document titled, "Nursing Practice Alert Infection Prevention and Control" indicated: 1. PPE will be used anytime when expecting contact with body fluids and environment contaminated with bodily fluids. 2. Good hand hygiene on room entry and exit, and prior to putting on and taking off gloves. 3. Strict hand hygiene on room entry and exit, and before contact with residents. 4. Disinfect/sanitize equipment after use with each resident. A review of the facility's "Hand Hygiene/PPE Observation Tool," dated 7/2018, indicated for all staff to observe hand hygiene before and after resident's care, PPE worn before entering and removed after exiting from resident's isolation room. A review of the facility's undated policy titled, "Standard Precautions", indicated the following: 1. Staff are to change gloves when moving from a contaminated body (private parts) site to a clean body site during patient care. This does not make sense, please check, it should be from clean to dirty. 2. Remove gloves after contact with a patient and or surrounding environment including medical equipment. 3. Non-critical movable medical equipment not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 54 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to keyboards, phones, must be cleaned and disinfected using approved disinfectants in accordance with manufacturers' instructions before use on another patient. 4. Remove PPE before leaving, exiting isolation room and ensure hands and clothing do not touch potentially contaminated environmental surfaces or items to avoid transfer of microorganisms. A review of the facility's policy titled "Cleaning of Moveable Medical Equipment," dated 6/2018, indicated moveable medical equipment is any equipment used for several residents is to be cleaned after each individual use. A review of the undated Infection Preventionist Job Description indicated one of the IP job functions is to collaborate with the infection prevention manager, to investigate clusters of infections or changes in patterns or infection. 16. On June 27, 2019 at 9:57 a.m., License vocational Nurse (LVN 6 ) was observed inside contact isolation room with WOW, power cord plug inside of the resident bathroom. LVN 6 was observed using keyboard and mouse with the same gloves that was used to provide care to the resident, then going into another contact isolation room. During an interview with Registered Nurse (RN 1) on July 5, 2019 at 9:00 am acknowledged improper infection control practices by LVN 6. 17. On June 28, 2019 at 8:30 a.m., Respiratory Therapist 1 (RT1) was observed inside contact isolation room with WOW; using keyboard and mouse with the same gloves that was used to provide care, then going into another contact isolation room. During an interview with RT 1 on July 5, 2019 at 8:30 am acknowledged improper infection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 55 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE control practices. 18. On July 1, 2019 at 7:50 a.m. Certified Nurse Assistant (CNA 11) was observe going into contact isolation room without wearing PPE. During an interview with CNA 11 on July 2, 2019 at 1:10 pm, CNA 11 acknowledged the improper infection control practices. 19. July 2, 2019, 2019 at 1:10 p.m., Respiratory Therapist (RT 2) was observed inside contact isolation room with WOW; using keyboard and mouse with the same gloves that was used to provide care, then going into another contact isolation room. During an interview with RT 2 on July 5, 2019 at 1:25 pm acknowledged the improper infection control practices. 20. On July 2, 2019 at 8:40 a.m., Respiratory Therapist (RT 3) was observed outside contact isolation room with WOW; then going inside the room touching the privacy curtain with bare hands giving LVN 7 a bottle of Dan Active (probiotic dietary drink that help strengthen body's defense system) without gloves on. During an interview with RT 3 on July 5, 2019 at 1:28 pm acknowledged the improper infection control practices. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 56 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555848 (X3) DATE SURVEY COMPLETED 07/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER 1322 W 6th St San Pedro, CA 90732 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F924 Corridors have Firmly Secured Handrails CFR(s): 483.90(i)(3)

F924 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/17/2019 §483.90(i)(3) Equip corridors with firmly secured handrails on each side. This REQUIREMENT is not met as evidenced by: Based on observation, and interview, the facility failed to ensure that part of a handrail for one of two nurses' station (Station 2) hallway was firmly affixed, and permanently secured to the wall. This deficient practice had the potential to cause injuries to the residents, visitors, and or staff. Findings: During an observation on 6/27/19 at 8:45 a.m., the end part of a handrail fell off when Resident 16's guest leaned his left hand against it. Concurrently, registered nurse 8 stated a resident and or guest could get injured as a result of the broken and loose handrail. A review of the facility's policy titled "Plant Operations and Maintenance," dated 11/11, indicated inspections, tours, rounds and schedules are systematically performed by qualified engineers. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JOPE11 Facility ID: CA930000436 If continuation sheet 57 of 57