Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Little Comp Of Mary Subacute Care Ctr during CMS and state inspections, most recent first.
Failure to provide timely incontinent care and suctioning. A dependent resident was found soiled with stool and urine in bed with a strong odor present, while another resident with a trach had secretions bubbling from the mouth and mucus in the nostril. Records showed both residents were fully dependent for ADLs, and staff interviews confirmed residents should not be left soiled for prolonged periods and suctioning should be provided as needed for residents unable to clear secretions.
Kitchen Sanitation and Food Storage Deficiencies: Staff observed multiple open food items without open dates, clean disposable food containers stored with trash and food particles, utility carts in the clean area with dried food particles and grime, and open aluminum cans left at a workstation. The dietary aide, cook, and dietary supervisor all acknowledged that opened items must be dated, cans should be discarded, and carts and containers must be stored and maintained in a sanitary manner.
Improper Trash Storage Outside Kitchen: Surveyors observed two uncovered trash cans outside the kitchen, with one overflowing with trash. The DS confirmed the cans were not covered and overflowing, and the DON stated trash cans should not be overflowing and need to be covered. The report also cited facility infection prevention policy and SOM guidance on covered waste storage and sanitary disposal of garbage and refuse.
Accessible Call Light Not Provided on Admission: A resident with hemorrhagic stroke, quadriplegia, and respiratory failure was observed without an accessible call light and mouthed that he could not move his body and did not have a call light. PT documented that he could not mobilize his neck or extremities and recommended a sip-and-puff call light. The family member, SW, NM, and DON all stated the resident should have had an accessible call light upon admission, and the facility policy assigned the licensed nurse/CNA responsibility for explaining call light use at admission.
PASARR Level 2 Referral Not Completed for A Resident with Intellectual Disability. A resident with cerebral palsy, intellectual disability, pneumonia, and chronic respiratory failure was re-admitted with severe functional dependence and limited communication ability. The PASARR Level 1 screening was positive for intellectual disability/developmental disability and required a Level 2 mental health evaluation referral, but RN and DON interviews confirmed the referral was missing.
The facility failed to individualize and carry out care plans for two residents. One resident with severe neurologic and respiratory conditions had a rash resolve and then recur, but no new care plan was developed when the rash returned and topical treatment was ordered. Another resident with intact cognition and a history of sexually inappropriate behavior toward female CNAs had a care plan for shift-by-shift behavior monitoring and psych consult as needed, but staff reported the behavior continued, specific monitoring was not documented, and no psych consult was provided.
A resident with quadriplegia, chronic respiratory failure, ventilator dependence, G-tube dependence, DM, and cognitive impairment had a persistent whole-body rash with itching and scattered red patches. The chart showed multiple topical and PRN antipruritic orders over several months, IDT notes that the family was concerned the rash was spreading, and a case management consult to obtain dermatology authorization for dry skin and scattered rashes, but the resident was not seen by Dermatology.
A resident with intact cognition and significant medical needs, including trach ventilation and wheelchair use, had documented inappropriate sexual behavior toward female CNAs, including sexual remarks, requests for intimate care he could perform himself, and an incident of exposing himself. Although the care plan called for behavior monitoring and psychiatric consult as needed, staff interviews and record review showed no specific behavioral monitoring, no physician notification, and no psychiatric evaluation to assess the behavior.
A resident’s bathroom linen hamper was observed with the lid open and soiled non-disposable isolation gowns hanging outside or not fully inside the hamper while EBP signage was posted at the room entrance. The resident had chronic respiratory failure, anemia, atrial fibrillation, and DVT, and was dependent on staff for toileting hygiene, bathing, and dressing. Staff stated the hamper should be closed and not overflowing, and the facility policy required covered hampers for soiled linen.
Failure to document flu vaccine refusal education: A resident who was nonverbal and unable to make decisions had flu vaccine refused by family, but the care plan did not show that the family was educated on the risks and benefits of refusal. The IP stated the family declined the vaccine twice and was not given the VIS, despite facility policy requiring the VIS and documentation of the education on the MAR.
Two CNAs failed to adhere to infection control practices, risking cross-contamination. One CNA did not change PPE between caring for two residents, while another placed clean linen on a soiled cart before attending to a resident. These actions violated the facility's Enhanced Barrier Precautions policy, which mandates consistent PPE use during high-contact care activities.
The facility failed to maintain safe and sanitary food storage and preparation practices. Food items were improperly dated and stored, leading to potential cross-contamination. The ice machine was found with residue, risking contamination, and a bucket of used grease was not cleaned, attracting pests. These deficiencies could lead to foodborne illness among residents.
The facility failed to maintain sanitary conditions in the dumpster area behind the kitchen. One dumpster was overfilled and uncovered, with trash scattered on the ground, including disposable gloves, plastic, paper, and food. This area was near the kitchen's loading and food delivery area. The Food Service Director acknowledged the issue and stated that housekeeping was responsible for cleaning the area, which should be kept clean to prevent pest attraction.
A resident with severe cognitive impairment developed a blood blister on the right big toe, which was not reported to CDPH as required. Despite medical evaluations indicating a possible fracture, staff interviews revealed no prior observations of the injury, and the cause remained unknown. The facility's policy mandates reporting such injuries to rule out abuse, but the incident was not reported, leading to a deficiency.
The facility failed to provide non-pharmacological interventions before administering PRN psychotropic medication to two residents, leading to unnecessary medication use. Both residents received Ativan without prior interventions, and PRN orders exceeded the 14-day limit without reassessment, contrary to facility policy.
A resident experienced significant weight loss due to the facility's failure to honor her cultural food preferences. Despite having a care plan for inadequate oral intake, the resident, who only speaks Korean, was not provided with her preferred foods. Staff interviews confirmed the lack of documentation and provision of cultural foods, leading to inadequate calorie consumption and weight loss.
The facility failed to label and date feeding equipment for three residents, risking infection. A resident's water bag and two residents' tube feeding bottles were not properly labeled or dated, despite their dependence on these for nutrition. Staff acknowledged the oversight, highlighting the importance of changing and labeling feeding equipment every 24 hours to prevent infection.
The facility failed to monitor antibiotic use for two residents whose conditions did not meet infection criteria. One resident was prescribed ampicillin for a UTI without symptoms, and another was given cephalexin for cellulitis without meeting diagnostic criteria. This indicates a lack of adherence to the facility's antibiotic stewardship program.
The facility failed to ensure that a resident's medications were administered by licensed personnel or a trained family member. The resident's family member applied Triad cream and Venelex ointment without documented training or a signed self-administration form, as required by the facility's policy.
Failure to Provide Timely Incontinent Care and Suctioning
Penalty
Summary
The facility failed to provide timely and appropriate ADL care for dependent residents, including incontinent care for two residents and suctioning for a resident with a tracheostomy. One resident was observed lying in bed with a large amount of brown soft stool on the buttocks, stool and urine in the underpad and gown, and a strong odor of stool in the room. The resident was grimacing and turned to the right side during the observation. The resident’s record showed diagnoses including UTI, traumatic brain injury, cervical neck fracture, PEG tube, and functional quadriplegia, and the MDS indicated dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene, with the resident always incontinent of urine and stool and at risk for pressure injury. A second resident was observed lying upright in bed on oxygen through a T-bar tracheostomy device with clear secretions bubbling and dripping from both sides of the mouth and thick greenish-yellow mucus discharge from the right nostril. The resident’s record showed chronic respiratory failure, tracheostomy status, anoxic encephalopathy, gastrostomy tube dependence, and diabetes mellitus. The MDS indicated the resident was comatose and dependent on staff for oral hygiene, toileting hygiene, and bathing. The care plan directed regular oral care, suctioning to reduce infection risk, and monitoring for airway patency. During interviews, staff stated residents should not be left soiled for more than 5 minutes, rounding should occur every 2 hours, and suctioning should be provided as needed for residents who cannot clear secretions. A CNA stated she had not seen one resident for the last three hours because her assignments were heavy. The respiratory therapist stated licensed nurses could suction orally and nasally and that not suctioning a resident with secretions in the mouth and nose in a timely manner can lead to aspiration pneumonia. Facility policies reviewed addressed care of incontinent residents and suctioning for residents unable to clear secretions by themselves.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to provide a safe and sanitary environment in the kitchen by not ensuring multiple open food items had open dates, including cooking oil, powdered brown gravy, cream of wheat, pancake mix, and corn starch. During observation in the kitchen, these items were found without open dates, and clean disposable food containers were observed stored in a plastic bin with trash and food particles. Two food utility carts in the clean area were also observed with dried food particles and dirt, and multiple open aluminum cans with dried food particles were observed at a workstation. During interviews, the dietary aide stated open aluminum cans should not be stored at a workstation and should be placed in the trash, noting they may spread germs and attract cockroaches and ants. The cook stated that every time a food item is opened it must be dated to ensure freshness and avoid contamination. The dietary supervisor stated he was aware of the concerns and confirmed that open food items must have open dates, open aluminum cans should be discarded, utility carts in clean areas must be cleaned after each use, and disposable food storage containers must be stored in a sanitary manner. Facility policies reviewed also stated that opened food items must be covered, labeled, and dated, disposable containers must be stored inverted on clean surfaces, and food service equipment and facilities must be cleaned and sanitized routinely.
Improper Trash Storage Outside Kitchen
Penalty
Summary
The facility failed to ensure garbage and refuse were properly disposed of outside the kitchen. During an observation on 1/26/26 at 9:12 am, surveyors found trash stored in two trash cans outside the kitchen that were not covered, and one of the cans was overflowing with trash. The observation documented that the trash was being kept in an area associated with kitchen waste storage. During interviews, the Dietary Supervisor stated on 1/29/26 at 9:15 am that the two trash cans were not covered and one was overflowing with trash, and that trash cans should not be overflowing and should be covered. The DON stated on 1/30/2026 at 7:26 am that trash cans should not be overflowing and need to be covered, and that there could be issues with pest control when trash is not disposed of properly. The report also cited the facility's Infection Prevention Program and Risk Assessment and the State Operations Manual guidance regarding covered waste storage and sanitary disposal of garbage and refuse.
Accessible Call Light Not Provided on Admission
Penalty
Summary
The facility failed to ensure that Resident 105 was provided an adaptive call light upon admission. During a concurrent observation and interview on 1/26/26 at 2:14 pm at the resident’s bedside, Resident 105 mouthed that he did not have a call light and could not move his body. The admission record showed the resident was admitted with diagnoses including hemorrhagic stroke, quadriplegia, respiratory failure, and GERD. The PT initial evaluation dated 1/26/26 documented that Resident 105 was unable to mobilize his neck, both upper extremities, and both lower extremities, and recommended a trial of a sip-and-puff call light. The resident’s family member stated the resident had not had a call light to call staff for assistance since admission. The SW stated the resident did not have an accessible call light and should have had one upon admission, and the NM and DON both stated all residents should have an accessible call light upon admission. The DON also stated he was aware that Resident 105 did not have a call light appropriate for his medical condition. The facility policy stated it was the responsibility of the licensed nurse/CNA, when admitting the resident, to explain the use of the call light and related communication devices.
PASARR Level 2 Referral Not Completed for Resident with Intellectual Disability
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for Resident 10. The resident was re-admitted to the facility with diagnoses including cerebral palsy, intellectual disability, pneumonia, and chronic respiratory failure. The MDS dated 11/5/2025 indicated the resident rarely had the ability to make self-understood or understand others, was severely impaired in task of daily life, and was dependent on nursing staff for eating, oral hygiene, toileting, showering, dressing, footwear, personal hygiene, and rolling from left to right. The resident's Notice of PASARR Level 1 Screening Results dated 11/4/2025 indicated the resident was positive for intellectual disability, developmental disability, or related conditions and required a PASARR Level 2 Mental Health Evaluation Referral. During interview, RN 5 stated residents with a diagnosis of any mental illness or psychiatric issues would need a Level 2 PASARR evaluation and stated Resident 10 needed that evaluation referral. The DON also reviewed the Level 1 screening and stated the Level 2 mental health evaluation referral was missing and that not receiving the evaluation referral resulted in the resident not receiving the appropriate level of care.
Failure to Update Care Plan for Recurrent Rash and to Implement Behavior Monitoring and Psych Consult
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for Resident 8 when a rash reoccurred. Resident 8 was admitted with diagnoses including persistent vegetative state, quadriplegia, chronic respiratory failure, ventilator dependence, and diabetes mellitus, and was documented as cognitively impaired and totally dependent for ADLs. The record showed the resident’s rash had resolved on the left lateral back, left upper back, left lateral leg, left upper quadrant, right lateral back, and right medial leg on 12/23/25, but the rash returned on 1/18/26 to the left and right upper arms and left and right groin areas. A vitamin A&D topical ointment order was entered on 1/19/26 for those areas, and RN 4 stated a new care plan should have been started when the rash returned. The facility also failed to implement the care plan for Resident 15’s inappropriate sexual behavior and failed to provide a psychiatric consult to assess the behavior. Resident 15 had diagnoses including pneumonia, muscular dystrophy, and chronic respiratory failure requiring nocturnal mechanical ventilation through a tracheostomy. The resident’s MDS indicated intact cognition and partial/moderate assistance with bathing, upper body dressing, and toileting hygiene. The care plan identified that the resident was verbally inappropriate toward staff, called staff names, made sexual remarks, and asked female staff to clean his private area despite being able to do it himself; interventions included monitoring behavior every shift and providing psychiatric consult as needed. Social work and nursing staff stated the inappropriate sexual behavior toward female CNAs had been occurring since 5/1/25, including requests for female staff to clean his private area and comments directed toward young women. SW 1 stated male CNAs were assigned because of the behavior and that no psychiatric consult had been provided. NM 1 stated three female CNAs reported concerns, the facility removed those CNAs from the resident’s care, and the resident was sometimes still assigned female CNAs because of inadequate male staffing. NM 1 also stated there was no documentation showing specific inappropriate sexual behavior was monitored as described in the care plan and no documentation that the physician was notified for a psychiatric consult order.
Failure to Obtain Dermatology Evaluation for Persistent Whole-Body Rash
Penalty
Summary
The facility failed to ensure Resident 8 was seen by a Dermatologist for an unresolved whole-body rash that began on 7/18/2025. During observation on 1/26/26, Resident 8 had scattered rashes with red patches all over the body. Resident 8’s admission record showed diagnoses including quadriplegia, chronic respiratory failure, ventilator dependence, gastrostomy tube dependence, and diabetes mellitus. The MDS dated 9/12/2025 indicated the resident was cognitively impaired and totally dependent for ADLs. Record review showed repeated skin treatments were ordered over several months for rashes affecting multiple body areas, including diphenhydramine cream, triamcinolone ointment, clotrimazole-betamethasone cream, hydrocortisone ointment, fluocinonide cream, triamcinolone ointment to multiple areas, Vitamin A&D ointment, and diphenhydramine via G-tube for itching. IDT care conference notes documented the family’s concern that the rashes were spreading and later described rashes on the left abdomen, left lateral flank, left upper arm, and then dry skin and scattered rashes to the entire body. A consultation to case management on 11/16/2025 indicated to obtain authorization for a dermatology consult for dry skin and scattered skin rashes to the entire body.
Failure to Monitor and Assess Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to ensure Resident 15 received necessary behavioral health care and services related to inappropriate sexual behavior toward female CNAs. Resident 15 was admitted with diagnoses including pneumonia, muscular dystrophy, and chronic respiratory failure requiring nocturnal mechanical ventilation through a tracheostomy. The resident’s MDS indicated intact cognition and use of a manual or electric wheelchair, with partial/moderate assistance needed for bathing, upper body dressing, and toileting hygiene. The care plan identified that Resident 15 was verbally inappropriate toward staff, called staff names, made sexual remarks, and asked female staff to clean his private area despite being able to do it himself. The care plan interventions included monitoring behavior every shift and providing psychiatric consult as needed. During interviews, Resident 15 and CNA 3 described an incident in which Resident 15 exposed himself and held his penis in front of CNA 3, and CNA 3 stated this had happened before but was not reported to the supervisor. Social work and nursing leadership stated Resident 15 had shown inappropriate sexual behavior toward female CNAs, especially younger women, and that male CNAs were sometimes assigned because of the behavior. Record review and staff interviews showed the facility did not document specific behavioral monitoring tied to the inappropriate sexual behavior, did not notify the physician about the behavior, and did not obtain a psychiatric consult to evaluate or assess it. The SW stated no psychiatric consult was provided, and the DON stated there were no specific behavioral monitoring notes addressing the behavior and no documentation that the physician was notified. Facility policy required reassessment with changes in psychosocial or emotional behavior patterns and required identification and addressing of residents with psychiatric problems.
Open Linen Hamper With Soiled Isolation Gowns in Resident Bathroom
Penalty
Summary
Infection control practices were not observed for one sampled resident when the linen hamper in the resident’s bathroom was found with its lid open and filled with soiled non-disposable isolation gowns that were hanging outside the hamper. During a later observation, the hamper was again open and some of the soiled yellow non-disposable gowns were not completely inside the hamper. Enhanced Barrier Precaution signage was posted outside the room, indicating gown and glove use during high-contact resident care activities. The resident’s face sheet showed diagnoses including chronic respiratory failure, anemia, atrial fibrillation, and deep vein thrombosis of the right leg. The MDS dated 11/3/2025 indicated the resident had intact cognition and was dependent on staff for toileting hygiene, bathing, and dressing. Staff interviews stated the hamper lid should be closed, the hamper should not be overflowing, and soiled linens and gowns should be fully contained inside the hamper; the facility’s Linen and Laundry Policy stated soiled linen should be handled with universal precautions and covered hampers should be used in all areas.
Failure to Document Flu Vaccine Refusal Education
Penalty
Summary
The facility failed to ensure that Resident 22 and the resident’s representative were provided education regarding the risks and benefits of refusing influenza vaccination. Resident 22 was readmitted with chronic respiratory failure with hypoxia, was nonverbal per the H&P, and was described on the MDS as comatose and unable to think or make decisions. The MDS also indicated Resident 22 did not receive the influenza vaccination for the 2025-2026 flu season. The care plan for absence of infection signs and symptoms documented that the family refused the flu vaccine for the 2025-2026 flu season, but it did not indicate that the family was educated regarding declination of the vaccine. During interview and record review, the Infection Preventionist stated the family declined the flu vaccine on two occasions but was not given the Vaccine Information Statement. The IP stated resident or family education regarding vaccine declination should be documented on the care plan, and that the VIS explains the risks of not receiving the vaccine and the benefits of receiving it. The facility policy stated that before immunization is offered, the resident or legal representative is to be given the appropriate VIS and that this education and the edition date are to be documented on the MAR.
Infection Control Breach by CNAs
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two separate incidents involving Certified Nursing Assistants (CNAs). In the first incident, CNA 1 provided care to Patient 2, who was in bed A, and then proceeded to Patient 1's bedside without changing the personal protective equipment (PPE) gown. Although CNA 1 removed gloves and performed hand hygiene, the gown was not changed due to a lapse in judgment when Patient 1 requested assistance. This oversight occurred despite the presence of an Enhanced Barrier Precautions (EBP) sign outside Patient 1's door, indicating the need for gown and glove use during high-contact patient care activities. In the second incident, CNA 2 placed clean linen intended for Patient 1 on top of a used soiled linen cart before proceeding to Patient 1's bedside. This action was taken after CNA 2 was distracted by Patient 2's coughing and went to assist with repositioning to maintain the patient's airway. After providing care to Patient 2, CNA 2 picked up the linen and soiled linen hamper and started towards Patient 1's side of the room, which led to a family member's concern. The facility's policy on Enhanced Barrier Precautions emphasizes the consistent use of PPE during high-contact care activities to prevent the spread of multidrug-resistant organisms, which was not adhered to in these instances.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Several food items in the walk-in refrigerator were not dated for thawing, and a box of pepperoni was stored uncovered in the walk-in freezer. Additionally, expired food items, such as black beans and cooked fruit, were found in the reach-in refrigerator. There was also improper storage of food items, with baked pastries and ready-to-eat turkey deli meat stored next to raw shelled eggs, and raw chicken thighs thawing next to raw ground beef, which could lead to cross-contamination. The ice machine in the facility was not maintained in a sanitary manner, with brown residue found inside the ice bin. This residue could potentially contaminate the ice, posing a risk to residents, staff, and visitors. The Food Service Director (FSD) acknowledged the issue and noted that the ice machine was not clean, and the residue could lead to contamination. A large bucket filled with used cooking grease, fat, and oil was stored under the kitchen counter, and it was not maintained in a clean manner. The bucket was covered with grease and residue, making it sticky to touch, which could attract pests and lead to the growth of microorganisms. The FSD confirmed that the bucket was reused without being cleaned, which could pose a risk of contamination in the kitchen.
Improper Trash Disposal Near Kitchen
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas behind the kitchen in a sanitary manner. During an observation and interview with the Food Service Director (FSD), it was noted that one of the six garbage dumpsters was overfilled with cardboard and trash, and its lid was open. Additionally, there was trash on the ground surrounding the dumpsters, including disposable gloves, plastic, paper, and food. This area was located in the loading and food delivery area next to the kitchen back door. The FSD acknowledged that housekeeping was responsible for cleaning the trash area and agreed that the area was dirty and should be kept clean to prevent attracting pests to the kitchen. The FDA Food Code 2022 requires that receptacles for refuse be kept covered with tight-fitting lids and stored in a manner that makes them inaccessible to insects and rodents.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for a resident who developed a blood blister on the right big toe. The resident, who was admitted with diagnoses including respiratory failure, cerebral vascular accident, and had a tracheostomy and gastrostomy tube, was found to have a blood blister by a CNA during a routine cleaning. The resident's Minimum Data Set indicated severely impaired cognitive skills and dependency on staff for various activities, with no prior skin issues noted. The incident was documented in the resident's progress notes, which detailed the discovery of the blood blister and subsequent medical evaluations, including an x-ray that suggested a possible nondisplaced fracture. Despite the documentation and the facility's policy requiring reporting of injuries of unknown origin within 24 hours, the incident was not reported to CDPH. Interviews with staff, including CNAs, LVNs, and the RN, revealed that the injury was not observed during prior assessments, and the cause of the blister remained unknown. The Director of Nursing confirmed that the facility's policy mandates reporting such injuries to rule out abuse or neglect. However, the RN involved did not report the incident, believing it was not abuse, and the House Supervisor was not instructed to report it either. This oversight in reporting the injury of unknown origin to the appropriate authorities constituted a deficiency in the facility's compliance with regulatory requirements.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that two residents, Resident 84 and Resident 96, were free from unnecessary psychotropic medications. For Resident 96, the facility did not provide non-pharmacological interventions before administering Ativan, a psychotropic medication, as needed for anxiety. The medication was administered without prior non-pharmacological interventions, and the PRN order exceeded the 14-day limit without reassessment by a physician. This oversight was confirmed by both a Licensed Vocational Nurse and a Registered Nurse, who acknowledged that the non-pharmacological interventions were documented after the administration of Ativan, contrary to the facility's policy. Resident 96 was admitted with severe cognitive impairment and was dependent on staff for daily activities. The resident had a history of anxiety and was prescribed Ativan to manage symptoms of agitation and restlessness. However, the facility's failure to implement non-pharmacological interventions before administering the medication and the continuation of the PRN order beyond 14 days without physician reassessment placed the resident at risk for adverse consequences. Similarly, Resident 84 was administered Ativan without prior non-pharmacological interventions, and the PRN order was extended beyond the 14-day limit without proper reassessment. Resident 84, who had intact cognition but was dependent on staff for daily activities, was prescribed Ativan for anxiety. The facility's policy required non-pharmacological interventions to be attempted first and PRN orders to be reassessed every 14 days, but these steps were not followed, leading to the unnecessary use of psychotropic medication.
Failure to Honor Cultural Food Preferences Leads to Resident Weight Loss
Penalty
Summary
The facility failed to honor the cultural food preferences of a resident, leading to significant weight loss. The resident, who only speaks Korean and has a history of serious medical conditions including respiratory failure and Moyamoya disease, was admitted with a gastrostomy tube for nutritional supplementation. Despite having a care plan indicating inadequate oral intake and frequent meal refusals, the facility did not document or provide the resident's preferred Korean foods, which contributed to the resident's weight loss. Interviews with staff revealed that the resident's cultural food preferences were not honored, and there was no documentation of these preferences. The resident was offered alternative foods like sandwiches, yogurt, and Jello, which did not align with her cultural preferences. The Registered Dietician admitted to not having met the resident or her family to ascertain her food preferences, despite the facility's policy requiring the RD to ensure cultural food preferences are granted. This oversight resulted in the resident consuming inadequate calories and experiencing weight loss.
Infection Control Lapses in Labeling and Dating of Feeding Equipment
Penalty
Summary
The facility failed to observe proper infection control measures for three residents, leading to potential risks of infection. Resident 29's water bag was not labeled or dated, which is crucial for monitoring and preventing infection. Resident 29 was readmitted with a history of a ruptured cerebral aneurysm and gastroparesis, and was dependent on a gastrostomy tube for nutrition due to dysphagia. The care plan for Resident 29 included monitoring for signs and symptoms of infection, but the lack of labeling on the water bag indicates a lapse in following these precautions. Resident 62's tube feeding bottle was also found to be unlabeled and undated during an observation. Resident 62 was readmitted with a subdural hematoma and chronic respiratory failure, and was comatose and dependent on tube feeding due to dysphagia. The Licensed Vocational Nurse (LVN) responsible for Resident 62 acknowledged the oversight, emphasizing the importance of changing and labeling tube feeding bottles every 24 hours to prevent infection. Similarly, Resident 86's tube feeding bottle was not dated, as confirmed by another LVN. Resident 86 was admitted with encephalopathy, a history of hemicraniectomy, respiratory failure, and dysphagia, and was also dependent on continuous tube feeding. The facility's policy requires labeling and changing of enteral formula containers and administration sets to prevent bacterial growth, but this was not adhered to, as evidenced by the observations and interviews with the staff and the Infection Prevention Nurse.
Inappropriate Antibiotic Use for Two Residents
Penalty
Summary
The facility failed to appropriately address and monitor the use of antibiotics for two residents, Resident 41 and Resident 98, whose conditions did not meet the McGeer criteria for infection. Resident 98 was admitted with diagnoses including respiratory failure and traumatic brain injury. Despite not showing symptoms of a urinary tract infection, Resident 98 was prescribed ampicillin for a UTI, as confirmed by the Infection Preventionist and Registered Nurse. The urine specimen collected did not meet the criteria for a true infection, yet the antibiotic was administered, indicating a lack of adherence to the facility's antibiotic stewardship program. Resident 41, admitted with conditions such as respiratory failure and a cerebral vascular accident, was prescribed cephalexin for cellulitis on the right big toe. The Infection Preventionist confirmed that the resident did not meet the McGeer criteria for cellulitis, as there was no pus or drainage present, and only three signs of infection were observed. Despite this, the antibiotic was administered based on the physician's order, without proper adherence to the criteria set for diagnosing a true infection. The facility's policy promotes the appropriate use of antimicrobials, yet the actions taken in these cases did not align with the policy's guidelines. The Infection Preventionist and Registered Pharmacist acknowledged the importance of using the McGeer criteria to prevent antibiotic resistance, but the facility's practices did not reflect this understanding, leading to the unnecessary administration of antibiotics to both residents.
Failure to Ensure Proper Medication Administration Training
Penalty
Summary
The facility failed to ensure that Patient 1's medications were administered by licensed personnel or a family member who had received proper training. Patient 1, who had chronic respiratory failure and moisture-associated dermatitis on the buttocks, was prescribed Triad cream and Venelex ointment for wound care. However, the Wound Care Nurse (WCN) confirmed that Patient 1's family member had been applying these medications without documented training or a signed self-administration medication form in the patient's record, as required by the facility's policy and procedure (P&P). The facility's P&P mandates that any patient or family member who wishes to self-administer medication must undergo training and sign a form to confirm completion. This form should be documented in the patient's electronic medical record (EMR). The WCN was unable to locate this form for Patient 1, indicating that the required training and documentation were not completed. This oversight had the potential to result in medication errors and ineffective treatment of Patient 1's wound, potentially delaying healing.
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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 San Pedro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seacrest Post-acute Care Center | 0 mi | ★★★★★ | 35 | 1 |
| Los Palos Post-acute Care Center | 0 mi | ★★★★★ | 4 | 0 |
| Palos Verdes Health Care Center | 3.1 mi | ★★★★★ | 24 | 0 |
| Lomita Post-acute Care Center | 4.2 mi | ★★★★★ | 29 | 0 |
| Torrance Memorial Med Ctr Snf/dp | 5.4 mi | ★★★★★ | 3 | 0 |
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