A list of the most recent deficiencies for Little Sisters of The Poor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-11 | 2023-03-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-06 | 2023-01-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-06 | 2023-01-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-06 | 2023-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-06 | 2023-01-20 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-01-06 | 2023-01-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-01-06 | 2023-01-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-06 | 2023-01-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-06 | 2023-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-06 | 2023-01-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-11 | 2023-01-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-11 | 2023-01-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-11 | 2023-01-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-11 | 2023-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-07 | 2022-01-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-03 | 2021-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-03 | 2021-12-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-03 | 2021-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-03 | 2021-12-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-07 | 2021-12-18 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-12-07 | 2021-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-07 | 2021-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-07 | 2021-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-07 | 2021-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-08 | 2021-11-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-09 | 2020-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-10-13 | 2020-10-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-13 | 2020-10-27 | N |
| Use approved construction type or materials. | Fire Safety | 2020-10-13 | 2020-10-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-13 | 2020-10-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-10-13 | 2020-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-13 | 2020-10-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-10-13 | 2020-10-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-10-13 | 2020-10-14 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2020-10-13 | 2020-10-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-10-13 | 2020-10-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-13 | 2020-10-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-13 | 2020-10-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-10-13 | 2020-10-13 | N |
