PROVIDENCE LITTLE COMP OF MARY SUBACUTE CARE CTR Inspection Report, Violations & Safety Grade (SAN PEDRO, California)

1322 WEST SIXTH STREET, SAN PEDRO, California 90732

Phone: 3107914518

CMS Overall:4/5

Overview & Bed Count

Certified Beds

125

Avg Residents/Day

99.9

Ownership

Non profit - Corporation

Provider Type

Medicare and Medicaid

County

Los Angeles

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall4/5

Health4/5

Staffing4/5

Quality4/5

Nurse Staffing Check

Metric	This Facility	California Avg	Difference
RN Hours per Resident per Day	2.02	0.68	+1.35
Total Nurse Hours per Resident per Day	8.73	4.54	+4.19
CMS Staffing Rating	4/5	3.3/5	-
Nursing Staff Turnover	25.6%	36.6%	-

Health Citation History

31 health citations on record

Date	Category	Description	Severity
2026-01-30	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2026-01-30	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-01-30	Nutrition and Dietary Deficiencies	Dispose of garbage and refuse properly.	E – Moderate Harm Potential
2026-01-30	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2026-01-30	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2026-01-30	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2026-01-30	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2026-01-30	Quality of Life and Care Deficiencies	Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	D – Moderate Harm Potential
2026-01-30	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2026-01-30	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	D – Moderate Harm Potential
2025-01-16	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2024-12-06	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2024-12-06	Nutrition and Dietary Deficiencies	Dispose of garbage and refuse properly.	E – Moderate Harm Potential
2024-12-06	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2024-12-06	Pharmacy Service Deficiencies	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.	D – Moderate Harm Potential
2024-12-06	Nutrition and Dietary Deficiencies	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.	D – Moderate Harm Potential
2024-12-06	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2024-12-06	Infection Control Deficiencies	Implement a program that monitors antibiotic use.	D – Moderate Harm Potential
2023-12-14	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	K – Immediate Jeopardy
2023-12-14	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-12-14	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	E – Moderate Harm Potential
2023-12-14	Quality of Life and Care Deficiencies	Provide for the safe, appropriate administration of IV fluids for a resident when needed.	E – Moderate Harm Potential
2023-12-14	Quality of Life and Care Deficiencies	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.	E – Moderate Harm Potential
2023-12-14	Administration Deficiencies	Have a plan that describes the process for conducting QAPI and QAA activities.	E – Moderate Harm Potential
2023-12-14	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2023-12-14	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2023-12-14	Quality of Life and Care Deficiencies	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.	D – Moderate Harm Potential
2023-12-14	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2023-12-14	Nursing and Physician Services Deficiencies	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.	D – Moderate Harm Potential
2023-12-14	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	D – Moderate Harm Potential
2023-11-03	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential

Fire Safety Citation History

4 fire safety citations on record

Date	Category	Description	Severity
2026-01-30	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential
2023-12-14	Emergency Preparedness Deficiencies	List the names and contact information of those in the facility.	C – Minimal Harm Potential
2023-12-14	Smoke Deficiencies	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	C – Minimal Harm Potential
2023-12-14	Smoke Deficiencies	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	C – Minimal Harm Potential

Total Penalties & Fines

$11,170

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2023-12-14	Fine	$11,170	-

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