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Deficiency Records for Little Sisters of The Poor

View the most recent health deficiencies and inspection results for Little Sisters of The Poor. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Little Sisters of The Poor. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2026-01-22 2026-03-05 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2026-01-22 2026-03-05 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2026-01-22 2026-03-05 N
Have properly located and lighted "Exit" signs. Fire Safety 2026-01-22 2026-01-30 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2026-01-22 2026-01-30 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2026-01-22 2026-01-30 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2026-01-22 2026-01-30 N
Have proper medical gas storage and administration areas. Fire Safety 2026-01-22 2026-01-30 N
Conduct testing and exercise requirements. Fire Safety 2026-01-22 2026-01-30 N
Provide training in compliance and ethics. Health 2025-12-03 2025-12-18 Y
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2025-12-03 2025-12-18 Y
Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. Health 2025-12-03 2025-12-18 Y
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Health 2025-12-03 2025-12-18 Y
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Health 2025-12-03 2025-12-18 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-12-03 2025-10-06 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2025-05-21 2025-06-13 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2025-05-21 2025-06-13 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-04-16 2025-05-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-04-16 2025-05-16 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2025-04-16 2025-05-16 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-11-27 2025-01-24 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 2024-11-27 2025-01-24 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-11-27 2025-01-24 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-11-27 2025-01-24 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 2024-11-27 2025-01-24 N
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2024-11-27 2025-01-24 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 2024-11-27 2025-01-24 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-11-27 2025-01-24 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2024-11-27 2025-01-24 N
Provide training in compliance and ethics. Health 2024-11-27 2025-01-24 N
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Health 2024-11-27 2025-01-24 N
Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. Health 2024-11-27 2025-01-24 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2024-11-27 2025-01-24 N
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2024-11-27 2025-01-24 N
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Health 2024-11-27 2025-01-24 N
Provide and implement an infection prevention and control program. Health 2024-11-27 2025-01-24 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2024-11-27 2025-01-24 N
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. Health 2024-11-27 2025-01-24 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2024-11-27 2025-01-24 N
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Health 2024-11-27 2025-01-24 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-11-27 2025-01-24 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-11-27 2025-01-24 Y
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 2024-11-27 2025-01-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-11-27 2024-11-27 N
Have an enclosure around a vertical opening shaft. Fire Safety 2024-11-27 2024-11-27 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-12-08 2024-01-12 N
Provide and implement an infection prevention and control program. Health 2023-12-08 2024-01-12 N
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2023-12-08 2024-01-12 N
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. Health 2023-12-08 2024-01-12 N
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. Health 2023-12-08 2024-01-12 N
Provide enough food/fluids to maintain a resident's health. Health 2023-12-08 2024-01-12 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-12-08 2024-01-12 N
Ensure each resident receives an accurate assessment. Health 2023-12-08 2024-01-12 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-12-08 2024-01-12 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-12-08 2023-12-21 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-12-08 2023-12-21 N
Provide properly protected cooking facilities. Fire Safety 2023-12-08 2023-12-21 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-12-08 2023-12-21 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-12-08 2023-12-21 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-12-08 2023-12-21 N

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