PROVIDENCE LITTLE COMP OF MARY SUBACUTE CARE CTR

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2026

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has no plan of correction

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Implement a program that monitors antibiotic use.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 7, 2024

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 30, 2023

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 4, 2023

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024