Providence Little Comp Of Mary Subacute Care Ctr

Based on observation, interview, and record review the facility failed to maintain infection control practices when: 1.Certified Nursing Assistant 1 (CNA 1) provided care to Patient 2 then proceeded to Patient 1s bedside without changing CNA 1s personal protective equipment (PPE) gown prior to initiating care for Patient 1. 2.CNA 2 placed clean linen intended for Patient 1 on top of a used soiled linen cart and proceeded to Patient 1s bedside to initiate care. These deficient practices had the potential to cause cross-contamination (the unintentional physical movement or transfer of harmful bacteria from one person, object, or place to another) of infectious pathogens (bacteria and microorganisms) from patient to patient and/or within the facility. Findings: During an observation on 1/15/25 at 10:30 AM, an Enhanced Barrier Precautions ([EBP] measures that use gowns and gloves to reduce the spread of infection) sign is posted outside Patient 1s door which indicated when entering the room, providers and staff must apply a gown and gloves. This is a double occupancy room with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1.Several food items were not dated for thaw date in the walk-in refrigerator. One box of pepperoni was stored uncovered in the walk-in freezer. One medium container of black beans with expire date of 12/1/2024, one large container of blueberry sauce for toppings and one large container of cooked apple with an expire date of 11/30/2024 exceeding storage period for the food were stored in the reach in refrigerator. Two boxes of (baked pastry) and one package of sliced ready to eat turkey deli meat were stored on the shelf next to raw shelled eggs. One box of raw chicken thighs thawing on the shelf next to raw ground beef. This had the potential to cross contaminate food and result in food borne illness in 14 residents who received food from the kitchen. 2. Ice machine was not maintained in a sanitary manner and the inside compartment of the ice machine was stained and dirty. This deficient practice had the potential to cross contaminate food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas located in the loading and food delivery area behind the kitchen were maintained in a sanitary manner. One of six garbage dumpsters had the lid open, the dumpster was uncovered and overfilled with cardboard, and trash. There were disposable gloves, plastic, paper, and food on the ground surrounding the trash dumpsters. The trash was in the loading and food delivery area next to the kitchen back door. This deficient practice had the potential for harborage and feeding of pests, which may be attracted into the facility kitchen. Findings: During a concurrent observation and interview with the Food Service Director (FSD) on 12/3/2024 at 11:15AM, there were a total of six large trash bins. One trash bin was full of cardboard boxes and bags of trash, the dumpster was overfilled and not covered. There was trash on the floor including disposable gloves, paper, plastic wraps, and food. During a concurrent interview with the FSD, the FSD stated housekeeping is responsible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to the California Department of Public Health (CDPH) for one of two sampled residents (Resident 41) when Resident 41 developed a blood (a fluid-filled sac in the outer layer of skin) blister on the right big toe of the right foot. This failure had the potential to result into a delayed investigation to rule out abuse. Findings: During a review of Resident 41's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included respiratory failure (condition when the lungs are not able to effectively take in oxygen and remove carbon dioxide from the blood), cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 84 and Resident 96) were free of unnecessary psychotropic (any drug that affects the brain activities associated with mental processes and behavior) medications by failing to: 1.Ensure Resident 84 and Resident 96 were provided with non-pharmacological interventions (intervention that does not primarily use medicine before administering a prn (as needed) psychotropic medication. 2. Ensure prn psychotropic medication use had not exceeded 14 days. These failures placed Resident 84 and Resident 96 at risk for adverse consequences (unintended, harmful events attributed to the use of medication) due to unnecessary prolonged use of psychotropic medication. Findings: During a review of Resident 96's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including respiratory failure ( serious condition when the lungs cannot get enough oxygen into the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure one of 22 sampled residents (Resident 46's food and cultural preferences were honored. This failure resulted in weight loss due to inadequate consumed calories for residents who did not receive the food items of their choices and preference. Findings: During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was admitted to the facility on [DATE] with a diagnoses including respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide). During a review of Resident 46's History and Physical (H&P), dated 6/11/2029, the H&P indicated Resident 46 had diagnoses of but not limited to craniotomy (a surgical procedure that involves removing a piece of the skull to access the brain), cerebrovascular accident (stroke, loss of blood flow to a part of the brain) with hemiplegia (paralysis of one half of the body) and Moyamoya disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures for three of 10 residents (Resident 29, 62, and 86) by failing to: 1. Ensure Resident 29's water bag was labeled and dated. 2. Ensure Resident 62's tube feeding bottle was labeled and dated. 3. Ensure Resident 86's tube feeding bottle was dated. These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Residents 29, 62, and 86. Findings: 1.During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was re-admitted to the facility 11/1/2024. During a review of Resident 29's History and Physical (H&P), the H&P indicated Resident 29 was admitted with diagnoses of ruptured cerebral aneurysm (a weak spot in a blood vessel in the brain, like a tiny balloon, has burst open, causing bleeding in the surrounding brain tissue) and gastroparesis (stomach muscles are weakened or impaired, causing food to remain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address and monitor the use of antibiotic on two of five sampled residents (Resident 41 and Resident 98) when residents' conditions or symptoms did not meet McGeer criteria(a set of criteria used in long term care facilities to determine if signs and symptoms constitute a true infection). This failure had the potential to result in Resident 41 and Resident 98 developing resistance (antibiotic will not be effective to treat infection) from unnecessary or inappropriate use of antibiotic. Findings: a. During a review of Resident 98's admission Record, the admission Record indicated the resident was admitted on [DATE] facility with diagnoses that included respiratory failure (condition when the lungs are not able to effectively take in oxygen and remove carbon dioxide from the blood). During a review of Resident 98's History and Physical (H&P), dated 10/26/2024, the H&P indicated Resident 98 had diagnoses of but not limited to traumatic brain injury (TBI-a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1. Label multiple canned foods, meat products, and vegetables with opened date and received date. 2.Ensure [NAME] 2 did not repeatedly placed the plastic serving spoon in the soiled area and used it to transfer food to the plate. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for residents residing in the facility. Findings: During a facility kitchen tour observation on 12/11/2023 at 9:35 a.m., observed multiple canned foods with no received date, observed multiple seasoning goods that were opened but not labelled with open date. During an interview on 12/11/2023 at 9:40 a.m. with the Dietary Director, stated that all canned foods, meat products, and vegetables delivered to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident Minimum Data Set ([MDS] a resident standardized assessment and care screening tool) assessment was transmitted within 14 days after completion for one of five sampled residents (Resident 3). This deficient practice resulted in late data transmitted to Centers for Medicare and Medicaid Services (CMS) regarding Resident's 3 medical status while in the facility. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnoses including respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). During a review of Resident 3's quarterly Assessment Reference Date (ARD [the end date of the observation period and provides a common reference point for all team members…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the licensed nurses failed to follow the facility policy and procedure (P&P) for initiation and maintenance of intravenous therapy ([IV] a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) for three of three residents (Residents 92, 65 and 49) as evidenced by: 1.Failing to label and date a peripheral intravenous catheter ([PIV] a short catheter inserted through a peripheral vein for the administration of solution or medication) site for Resident 65. 2.Failing to label and date extension tubing (tubing that is connected to the intravenous catheter upon insertion) to administer solution or medication directly into the resident vein. 3.Failing to obtain a physician order (PO) to insert a PIV in Residents 49 left foot. These deficient practices have the potential to result in harm and lead to development of infection, infiltration (accidental leakage of non-vesicant solutions out of the vein into the surrounding tissue)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for six of seven sampled residents (Resident 39,45,20,11,68 and 27), as indicated in the facility's policy and procedure by failing to: 1. Assess and complete the Bed Rail Use and Entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) Risk Assessment for Resident 39,45,20,11,68 and 27 per facility's policy and procedure (P&P). 2. Implement a care plan for the use of bed rails. These deficient practices had the potential to physical harm from possible entrapment (when a person is trapped by the bed rail in a position they cannot move from) from the use of bed rails for Resident 39,45,20,11,68 and 27. During an observation on 12/11/2023 at 11:55 a.m. at Resident 39's bedside, Resident 39 was observed non-verbal with a soft wrist restraint on the right wrist, a soft mitten restraint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to: 1.Reach QAPI goal of 100% for Restraint Reason Justification for the third quarter 2023 (July, August, and September). 2.Reach QAPI goal of 100% for Restraint Assessment for the third quarter 2023 (July, August, and September). 3.Reach QAPI goal of 100% for Restraint Documentation for the third quarter 2023 (July, August, and September). 4.Reach QAPI goal of 100% for Restraint Documentation for the third quarter 2023 (July, August, and September). These deficient practices placed for 12 residents out 95 who were on physical restraints (devices that limit a patient's movement) at risk for impaired blood circulation with possible formation of venous stasis ulcers (medical condition characterized by impaired blood flow in the veins), skin injuries including pressure ulcer (an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures by failing to: 1.Practice hand hygiene after removal and before putting on a new pair of gloves during medication pass observation. 2.Clean blood pressure machine ( BP- measurement of the force of blood that is flowing through the blood vessels) after using on Resident 30. 3. Dispose used gown to the designated trash bin inside the resident's room. 4.Ensure doffed off (to remove or take off) used personal protective equipment ([PPE] protective clothing, garments or equipment designed to protect the wearer or the resident from infections) such as gloves and gown while walking in the hallway. These failures had a potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for spread of infection. Findings: 1.During a medication pass observation on 12/14/2023, at 10:05 a.m. with Licensed Vocational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure call light was within reach on one of six sampled residents ( Resident 75). This failure had the potential to result in a delay of treatment for Resident 75 pain on the right side of her body and inability for Resident 75 to obtain necessary care and services. Findings: During a review of Resident 75's admission Record (Face Sheet), the Face Sheet indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including sepsis (life threatening complication of an infection), functional quadriplegia ( complete immobility due to severe disability or frailty from other medical condition), amyotrophic lateral sclerosis ( [ALS] nervous disease that affects nerve cells in the brain and spinal cord causing loss of muscle control) diabetes, and acute on chronic respiratory failure ( inability of lungs to meet oxygen needs of the body). During a review of Resident 75's Minimum Data Set ([MDS] standardized assessment and care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of six sample residents (Resident 11 and Resident 20) received the care and services necessary to prevent complications while managing their gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) while providing care by failing to: 1.Ensure Resident 11's G- tube was assessed for feeding tolerance during medication pass observation. 2.Ensure Resident 20's tube feeding ( liquid form of food that is delivered through the body through a flexible tube called gastrostomy tube) was labeled and dated appropriately according to the facility's Policy & Procedure (P&P). These deficient practices had the potential to cause Resident 11 to have intolerance to the feeding which could have caused diarrhea, nausea, vomiting, and aspiration (inhalation of foreign materials) which could lead to pneumonia (a lung infection), and had the potential to result in Resident 20 at risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 11) had an adequate amount of oxygen in the portable oxygen tank ( light, small tank that allow resident to receive supplemental oxygen ) while attending an activity and while in the patio. This failure had the potential to affect Resident 11's breathing and could cause desaturation (low blood oxygen concentration) from not receiving adequate amount of oxygen. Findings: During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including history of hemorrhagic stroke (blood vessels rupture in or near the brain which can cause permanent damage to the brain), tracheostomy (opening in the windpipe that provides an alternative airway for breathing), chronic respiratory failure( occurs when the lungs cannot get enough oxygen into the blood which makes it difficult to breathe), ileostomy (opening in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 49) received care and services for the provision of parenteral fluids (medication administered in a manner other than the digestive system) consistent with professional standards of practice by failing to : 1. Ensure staff followed the facility's policy and procedure (P&P), titled, Comprehensive Vascular Access Management prior to the insertion of a peripheral intravenous catheter ([IV] a line inserted into the skin used to give fluids and medications) into Resident 49's left foot. 2. Ensure nursing staff assessed and monitored Resident 49's IV site appropriately during the administration of medication through his left foot IV. These deficient practices resulted in Resident 49 having an IV inserted into his left foot without a physician's order (a formal request for a specific action to be carried out by the medical staff, such as administering a medication, conducting a diagnostic test, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1.Ensure it was free of medication error rate of five percent or greater during the medication pass observation by failing to administer two medications on one of four sampled residents (Resident 30) as ordered by the physician. 2.Check or verify name and date of birth of Resident 30's with his identification band ([ID] an armband that ensures accurate identification and includes the name and date of birth of a resident) before administering medications. These failures resulted to a medication error of 8 percent (%) out of 25 opportunities and had the potential to give medications to a wrong resident. Findings: During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including respiratory failure (condition when the lungs cannot get enough oxygen to meet body's demands), seizure(uncontrolled electrical activity between brain cells causing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure for one of the two sampled patients (Patient 1), Patient 1's medications was administered by a licensed personnel or the patient's family member who had received educational training on the administration of Venelex ointment (a topical medication use in the management of wound) and Triad cream (a topical medication use in the management of wound) in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in medication error and for Patient 1's wound to have an ineffective treatment and delayed healing of the wound. Findings: During a review of Patient 1's PCP (primary care provider) Meeting Progress Note, dated 10/19/2023, the progress note indicated Patient 1's assessment and plan included chronic respiratory failure (a condition where there's not enough oxygen in the body). In addition, the note indicated Patient 1 had a moisture-associated dermatitis to the buttocks and the plan was to treat with topical care and nutritional support. During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.