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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-04 | 2023-05-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-04 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-05-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-04 | 2023-05-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-04-04 | 2023-05-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-30 | 2023-05-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-30 | 2023-05-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-30 | 2023-05-15 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-30 | 2023-05-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-30 | 2023-05-15 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-03-30 | 2023-05-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-30 | 2023-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-30 | 2023-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-30 | 2023-05-15 | 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 | 2023-03-30 | 2023-05-15 | 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 | 2023-03-30 | 2023-05-15 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-03-30 | 2023-05-15 | N |
| Post nurse staffing information every day. | Health | 2023-03-30 | 2023-05-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-30 | 2023-05-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-30 | 2023-05-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-30 | 2023-05-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-03-30 | 2023-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-30 | 2023-05-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-30 | 2023-05-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-30 | 2023-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-30 | 2023-05-15 | N |
| Keep all essential equipment working safely. | Health | 2023-03-30 | 2023-05-15 | N |
| Meet other general requirements. | Fire Safety | 2019-03-14 | 2019-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-14 | 2019-04-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-14 | 2019-04-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-04 | 2019-03-12 | N |
| 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. | Health | 2019-01-04 | 2019-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-10-03 | 2017-11-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2017-10-03 | 2017-11-15 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-10-03 | 2017-11-15 | N |
