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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-07 | 2024-02-23 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-02-01 | 2024-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-01 | 2024-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-02-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-01 | 2024-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-01 | 2024-02-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-01 | 2024-02-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-01 | 2024-02-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-02-01 | 2024-02-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-01 | 2024-02-23 | 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 | 2024-02-01 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-01 | 2024-02-23 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2024-02-01 | 2024-02-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-04 | 2023-11-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-04 | 2023-11-17 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-10-04 | 2023-11-17 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-10-04 | 2023-11-17 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-10-04 | 2023-11-17 | Y |
| Post nurse staffing information every day. | Health | 2022-11-10 | 2022-12-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2022-12-08 | 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 | 2022-11-10 | 2022-12-08 | N |
| 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. | Health | 2022-11-10 | 2022-12-08 | 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 | 2022-11-10 | 2022-12-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-10 | 2022-12-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-10 | 2022-12-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-19 | 2021-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-23 | 2021-09-29 | 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 | 2021-08-23 | 2021-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-23 | 2021-09-27 | 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 | 2021-08-23 | 2021-09-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-19 | 2021-09-24 | N |
