Providence Little Co of Mary Transitional Care CTR

In the surveyor’s words

From the most serious findings on record at Providence Little Co of Mary Transitional Care CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 15, 2024

  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 and date an opened container of carrots, and bread rolls, and discard stored expired cooked chicken meat and expired cooked beef meat. 2) Ensure the executive chef handed food to Cook 1 while wearing gloves. 3) Ensure Cook 2 did not repeatedly touch the serving plate during food preparation without gloves. […]

• No harm, potential for more than minimal, widespreadF584Sep 9, 2022

  Based on observation, interview, and record review, the facility failed to provide a safe, comfortable environment to support a daily living safely, regarding safe temperature levels of 71 to 81 degrees Fahrenheit (F, unit of temperature) for 41 of 41 residents residing in the facility. This deficient practice had the potential to place the residents at risk of dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occurs after exposure to high temperatures). Findings: On September 9, 2022, at 3:05 p.m., a Facility Reported Incident investigation was initiated regarding the facility's HVAC (Heating, Ventilation and Air Conditioning) system, that was not functioning properly. […]

• No harm, potential for more than minimal, patternF578Mar 28, 2025

  Based on interview and record review, the facility failed to ensure residents' medical records updated to show documentation that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed and written information was provided to the residents and /or responsible parties for two of five residents (Residents 89 and 195). This failure violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: During a review of Resident 89's Admission Record, the Admission Record indicated Resident 89 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF726Mar 28, 2025

  Based on interview and record review the facility failed to ensure Certified Nursing Assistant's (CNA's) annual skills competencies were completed for CNA 2 and CNA 3 . These failures had the potential to put the resident's safety at risk during care. Findings: During a concurrent interview and record review on [DATE] at 10:45 a.m. with the Director of Staff Development (DSD), CNA 2 and CNA 3's Education & Professional Practice Competency Checklists. The DSD stated CNA 2 was hired on [DATE] and her last competency was done on [DATE]. The DSD stated CNA 3 was hired [DATE] and that her last skills competency was done on [DATE]. The DSD stated competencies are done annually. DSD stated we need to make sure that the staff are still preforming their skills appropriately. […]

• No harm, potential for more than minimal, patternF755Mar 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure Resident 20's physician orders for losartan (a medication used to treat hypertension [HTN - high blood pressure]) and hydrochlorothiazide (a medication used to treat HTN) indicated hold parameters for medications based on resident's blood pressure readings, affecting one of five sampled residents reviewed for medication administration. This deficient practice had the potential to result in medication errors, blood pressure abnormalities and heart complications for Resident 20. Findings: During a review of Resident 20's Admission Record, dated 3/26/2025, the Admission Record indicated, Resident 20 was admitted to the facility on [DATE]. […]