Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Little Co Of Mary Transitional Care Ctr during CMS and state inspections, most recent first.
Failure to assess and order self-administration of inhaler: A resident with COPD, cataract, and DM was observed keeping and using an albuterol puff inhaler at the bedside. The resident said she used it one to three times daily and relied on it when short of breath. RN and DON confirmed there was no self-administration assessment, education, or physician order in the record before the resident was allowed to self-administer the medication, despite facility policy requiring assessment and provider order.
A resident with HTN and DM had a non-functional overhead light in her room, despite being cognitively intact and needing touching assistance with ADLs. She told staff she had reported the problem and wanted the light working so she could read paperwork at night. An RN confirmed the light would not turn on, and POM later said he mistakenly marked the work order complete after confusing it with another room’s light. The facility policy required adequate and comfortable lighting levels and a safe, comfortable environment.
Failure to Notify Physician and Recheck Abnormal Vital Signs: A resident with HTN, CAD, DM, dysphagia, and AKI on dialysis had a BP of 98/43 after returning from dialysis and appeared weak. Staff reported the low BP but did not document physician notification, recheck the vital signs, or complete SBAR; later the resident became non-responsive, CPR was started, 911 was called, and the resident was pronounced dead.
Pain medication was not managed according to ordered pain parameters for a resident with a T3-T4 compression fracture and other diagnoses. The resident’s MAR showed Norco 10/325 mg was given for pain rated 5, even though that dose was ordered for severe pain rated 7-10. RN and DON interviews confirmed the dose did not match the resident’s pain level and that the physician was not contacted for an order appropriate to the reported pain.
Failure to Use Required PPE During Care for a Resident on EBP: A resident with a sacral pressure injury and severe cognitive impairment was on EBP, but two RNs were observed changing the resident's gown and bed linen after vomiting without wearing a gown. Both nurses stated PPE should have been worn during direct care, and the DON confirmed PPE was required whenever providing direct care to the resident.
A resident with a walker and wheelchair, and needing assistance with transfers and toileting, did not have a working call light readily available. Staff observed that the call light would not activate the signal outside the room because it was not plugged in, and a CNA reported the issue had been noted earlier in the day. The DON stated nursing staff would not be able to meet the resident's needs if the call light was not functioning properly.
A resident admitted for rehab with failure to thrive, a right renal mass, and chronic diastolic CHF experienced a prolonged stay due to profound debility, need for 24/7 assistance, and inability to safely return home. An IDT conference documented that the resident was fully incontinent and required maximal assistance with ADLs and transfers. Case management emailed the resident’s responsible party proposing a discharge home with home health, and the responsible party objected, stating that a 30‑day discharge notice was required. The resident was discharged earlier than the proposed date, and interviews with the responsible party, SW, and DON confirmed that no 30‑day written discharge notice was provided and that facility policy did not address this requirement.
A resident with multiple medical conditions, profound debility, incontinence, and need for 24/7 assistance was known by staff to uncover themself, yet no specific interventions were added to the care plan to address this behavior. The resident’s responsible party observed the resident’s private areas exposed in a hallway, and staff referenced a “diaper-free clinic” approach. Review of the care plan audit trail and regulatory documentation confirmed there were no care plan updates for the uncovering behavior, contrary to facility policy requiring timely review and revision of care plans when new needs or changes occur.
A resident with HTN, hyperlipidemia, cardiomyopathy, and chronic back pain was moved multiple times for facility needs and room accommodations, including to make space for a male resident, a confused resident, and an FCI resident requiring continuous observation. The resident later requested additional moves, but the room change notification forms were not completed or signed for the room changes, and staff interviews confirmed written notice and consent were expected before room transfers.
A resident with a history of cerebrovascular accident and seizure disorder experienced an unwitnessed fall due to the facility's failure to conduct Morse Fall Risk Assessments every shift as required. The last assessment was completed 17 hours before the fall, missing two assessments. The facility's policy mandates assessments at admission, transfer, each shift, and upon any change in condition.
Failure to Assess and Order Self-Administration of Inhaler
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 90, received a self-administration assessment, education, and a physician order before self-administering an albuterol puff inhaler. Resident 90 was admitted with diagnoses including COPD, cataract, and DM, and the H&P dated 4/27/2026 indicated the resident was alert and oriented. During observation and interview on 4/29/2026, Resident 90 was seen holding an albuterol puff inhaler in her hand and stated she used it one to three times per day, describing it as her "lifeline" and saying it helped her feel safe when she had difficulty breathing. On 4/30/2026, RN 1 reviewed the record and stated there was no self-administration assessment or physician order for the inhaler in the medical record, and that residents may self-administer medications only after assessment and education. The DON stated she was aware Resident 90 had not been properly assessed to keep the inhaler at the bedside and that nursing staff were required to complete an assessment before allowing a resident to store or self-administer medication. The facility policy stated self-administration is allowed only when ordered by a physician/provider and when the resident is assessed as competent.
Non-Functional Overhead Light in Resident Room
Penalty
Summary
The facility failed to maintain a comfortable and safe environment when the overhead light in Resident 17’s room was not functioning. Resident 17 was admitted to the facility with diagnoses of HTN and DM, and her MDS indicated that her cognition was intact and that she required touching assistance with ADLs. A work order dated 4/25/2026 documented that Resident 17’s overhead light was not working, and the work order was marked completed on 4/27/2026. During observation and interview on 4/27/2026, Resident 17 stated she had informed staff that her overhead light was not working and said she wanted it to work so she could read her paperwork at night. RN 5 attempted to turn on the overhead light in Resident 17’s room and it did not turn on, and RN 5 stated the light should be working for Resident 17’s safety when it is dark. POM later stated he had made a mistake and marked the work order completed after confusing it with another room’s bed overhead light. The DON stated the light not working could cause Resident 17 to feel frustrated because she likes to read the paper. The facility policy stated residents have the right to a safe, clean, comfortable, and homelike environment and that adequate and comfortable lighting levels must be provided in all areas.
Failure to Notify Physician and Recheck Abnormal Vital Signs
Penalty
Summary
The facility failed to ensure timely physician notification and appropriate nursing interventions when Resident 69 experienced a change of condition after a blood pressure reading of 98/43 mm/Hg was obtained at 3:57 p.m. Resident 69 was admitted with diagnoses including HTN, CAD, DM, dysphagia, and acute kidney injury on dialysis. The resident’s MDS indicated dependence on nursing staff for several activities of daily living and need for substantial to moderate assistance with eating and oral hygiene. During interviews, LVN 1 stated the low blood pressure was abnormal, that the physician had not been notified in the record, and that licensed nurses were required to notify the RN supervisor immediately of any change of condition. LVN 1 stated that when vital signs are low, the nurse should notify the physician right away, elevate the resident’s legs, offer fluids, wait for medical orders, recheck the blood pressure, and transfer the resident to the GACH ER if necessary. RN 7 stated that if the physician was not notified of an abnormally low blood pressure, the issue would not be properly addressed, and that Resident 69 was fragile, on dialysis, and required prompt medical orders and interventions. CNA 4 stated the low blood pressure was reported to LVN 2, who said he would check on Resident 69, but the blood pressure was not rechecked. LVN 2 stated Resident 69 had returned from dialysis and appeared weak, and that he did not remember calling the physician or documenting the change of condition or completing an SBAR in the progress notes. The nursing progress notes later documented that Resident 69 became non-responsive, cold and clammy, not breathing, and pulseless at 9:10 p.m.; CPR was started, 911 was called, and the resident was pronounced dead at 10:30 p.m. The DON stated the licensed nurse should have ensured Resident 69 was stable, rechecked the vital signs, and notified the doctor immediately. The facility policy required prompt physician notification for sudden or marked adverse changes in signs or symptoms, including abnormal vital signs.
Pain medication given outside ordered pain parameters
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. Resident 40 was admitted with diagnoses including T3 to T4 compression fracture, prostatitis, and urinary retention. The resident’s MDS indicated he could understand others and express wants and ideas, used a walker and wheelchair, and needed assistance with transfers, toileting, dressing, personal hygiene, and rolling. The MDS also indicated the resident described his pain as mild. The facility failed to ensure pain medications were administered according to physician orders and pain level parameters and failed to ensure appropriate assessment and communication with the physician regarding the resident’s pain. The physician orders showed Norco 5-325 mg every four hours as needed for pain level 4-6 was discontinued on 4/15/2025. During record review, the MAR showed that on 4/26/2026 the resident received Norco 10/325 mg, which was ordered for severe pain rated 7 to 10, even though RN 3 stated the resident’s pain level was 5 and that this dose should not have been given for that level of pain. RN 3 stated the licensed nurse should have notified the physician and requested a different medication appropriate for the resident’s pain level. The DON stated the nurse should have contacted the physician to obtain an order for the appropriate pain medication based on the resident’s reported pain level, and that licensed nurses were administering a higher dose of pain medication that did not match the resident’s pain level.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure infection control measures were observed for one sampled resident who was on enhanced barrier precautions for a sacral pressure injury. Resident 87 was admitted with diagnoses including anemia, hypertension, and osteoarthritis, and the MDS indicated severe cognitive impairment and substantial to maximal assistance with ADLs. The active order summary showed an order for a sacral spine pressure injury to be cleaned with normal saline and covered with a foam dressing daily. During an observation in the resident's room after the resident vomited, RN 2 and RN 3 were observed changing the resident's gown and bed linen without wearing PPE, including a gown. In interviews, both nurses stated they should have been wearing appropriate PPE when providing direct care to the resident because of the Stage II pressure injury and to help prevent spread of infection and cross contamination. The DON stated the resident was on EBP for a pressure injury and that nursing staff were required to wear PPE whenever providing direct care to the resident. The facility policy on Enhanced Barrier Precautions stated EBP is used to prevent the spread of MDROs and is intended to reduce transmission of resistant microorganisms through healthcare workers and the healthcare environment.
Call light not functioning for resident needing assistance
Penalty
Summary
A functioning call light was not readily accessible for one sampled resident, Resident 40, who was identified as high risk for falls. Resident 40 was admitted with diagnoses including T3 to T4 compression fracture, prostatitis, and urinary retention. The MDS dated 4/22/2026 indicated the resident could understand others and express wants and ideas, used a walker and wheelchair, and needed partial to moderate assistance with lying down, sitting, and transferring, as well as supervision or touching assistance with toileting, dressing, personal hygiene, and rolling from left to right. During a concurrent observation and interview on 4/27/2026, two call lights were seen in Resident 40's bed, but when the resident pressed both buttons, the light outside the room did not activate. The resident stated the call light was not working. RN 6 then tested the call light and found one was not plugged into the wall outlet; after plugging it in, the outside light illuminated and RN 6 stated it was working. CNA 1 stated she had been told earlier that morning that the call light needed to be replaced, and CNA 2 stated she had obtained another call light but the cord repeatedly fell out of the wall outlet. The DON stated the nursing staff would not be able to meet Resident 40's needs if the call light was not functioning properly. The facility policy stated call lights are to be placed within easy reach and defective call lights are to be reported immediately.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. The resident had been admitted for rehab with diagnoses including failure to thrive, a right renal mass, and chronic diastolic congestive heart failure, and was documented as alert and oriented with adequate insight and judgment at admission. Subsequent hospital medicine notes described a markedly prolonged admission due to profound debility, need for 24/7 assistance, and inability to safely discharge home, with ongoing transitional care and long‑term placement planning. An interdisciplinary team conference documented that the resident was 100% incontinent of bowel and bladder, unable to perform toileting, and required maximum assistance with feeding, grooming, dressing, bathing, and transfers. A social worker note showed that case management emailed the resident’s responsible party proposing a specific discharge date to the responsible party’s home with home health. The responsible party replied by email stating they did not appreciate the discharge date being pushed onto them and that a 30‑day discharge notice needed to be presented to the resident and/or family. The resident was discharged on a date earlier than the proposed discharge date, and interviews with the responsible party, the social worker, and the DON confirmed that no 30‑day written discharge notice was provided to the resident or responsible party. The DON also stated that the facility’s policy did not mention the 30‑day written discharge notice and that they were not aware of this regulation.
Failure to Update Care Plan for Resident Uncovering Behavior Affecting Dignity
Penalty
Summary
The facility failed to update the comprehensive care plan to address a resident’s behavior of uncovering themself, which was necessary to maintain the resident’s dignity and rights. The resident was admitted for rehabilitation with diagnoses including failure to thrive, a right renal mass, and chronic diastolic congestive heart failure, and was documented as alert and oriented with adequate insight and judgment. Subsequent documentation showed the resident had profound debility, required 24/7 assistance, and needed maximum assistance with feeding, grooming, dressing, bathing, transferring, and was 100% incontinent of bowel and bladder and unable to perform toileting. Staff, including the Assistant Nurse Manager, reported that the resident tended to uncover themself at times and acknowledged that interventions and care plan updates should have been in place for this behavior to maintain dignity. The resident’s responsible party reported observing the resident’s private area from the waist down exposed to the public while standing in the hallway outside the resident’s room, and staff informed her that the facility was a “diaper-free clinic” to prevent skin and infection problems. A review of the care plan audit trail from late October through late February showed no updates or interventions addressing the resident’s uncovering behavior during the admission. The Regulatory Accreditation Program Manager confirmed that no intervention or care plan entry was found regarding the resident’s tendency to uncover themself. This was inconsistent with the facility’s policy requiring care plans to be initiated within 24 hours of admission and reviewed and updated whenever there is a new order, change of intervention, or when interventions become ineffective or not applicable.
Room Changes Made Without Consent or Written Notice
Penalty
Summary
The facility failed to obtain informed consent and provide written notice before changing one resident’s room assignment. The resident’s history and physical dated 6/23/25 documented hypertension, hyperlipidemia, cardiomyopathy, and chronic back pain after a fall, and noted the resident was admitted for further physical therapy and rehab. During interview and record review, the Nursing Director stated the resident was moved from room A to room B to accommodate a male resident, then later moved again from room B to room D because of a confused resident across from room B. The resident was also moved from room D to room C to accommodate an FCI resident requiring continuous observation by two guards, then moved from room C to room A to be closer to a patio exit door for smoke breaks, and later moved from room A to room E with two other female residents. The resident then requested to return to room A because the resident did not like room E. Review of the facility’s room change notification forms showed no forms for the resident’s room changes. The Nursing Director stated the resident did not sign the room change notification form and identified this as a gap. Staff interviews indicated that room changes were supposed to involve resident and/or family consent and written notification, and the facility policy stated residents would not be transferred to another room against their wishes unless given prior reasonable written notice.
Failure to Conduct Timely Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that a Morse Fall Risk Assessment was completed every shift for a resident, as required by the facility's policy on Fall Risk Assessment and Prevention. The resident, a female with a history of hemorrhagic cerebrovascular accident and seizure disorder, experienced an unwitnessed fall. The last fall risk assessment was conducted approximately 17 hours before the fall, missing two assessments that should have been completed every eight-hour shift. The Assistant Nurse Manager confirmed that the Morse Fall Risk Assessment was not conducted as per the policy, which mandates assessments at admission, transfer, each shift, and upon any change in condition. The facility's policy outlines that a score of 24 or greater on the Morse Fall Assessment indicates an increased fall risk, necessitating fall prevention actions. The failure to adhere to this policy potentially delayed the identification of the resident's fall risk and the implementation of necessary interventions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Earlwood | 0.1 mi | ★★★★★ | 31 | 0 |
| Torrance Care Center West, Inc | 0.1 mi | ★★★★★ | 7 | 0 |
| Driftwood Healthcare Center | 0.1 mi | ★★★★★ | 2 | 0 |
| Bay Crest Care Center | 0.6 mi | ★★★★★ | 49 | 1 |
| Del Amo Gardens Care Center | 1 mi | ★★★★★ | 14 | 0 |
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