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? |
|---|---|---|---|---|
| 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| Provide enough food/fluids to maintain a resident's health. | 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 |
| 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 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 |
| Provide and implement an infection prevention and control program. | Health | 2023-12-08 | 2024-01-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-08 | 2024-01-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-05 | 2023-12-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-05 | 2023-12-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-05 | 2023-12-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2023-12-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2023-12-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-05 | 2023-12-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-06 | 2023-03-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-06 | 2023-02-10 | 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 | 2023-01-06 | 2023-02-10 | 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 | 2023-02-10 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-06 | 2023-02-10 | 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 | 2023-02-10 | 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 | 2023-01-06 | 2023-02-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-06 | 2023-02-10 | 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 | 2023-01-06 | 2023-02-10 | 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 | 2023-02-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-05 | 2023-01-23 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-01-05 | 2023-01-23 | 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 | 2023-01-05 | 2023-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-05 | 2023-01-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-05 | 2023-01-23 | 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 | 2022-02-25 | 2022-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-25 | 2022-03-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-25 | 2022-03-10 | 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 | 2022-01-21 | 2022-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-21 | 2022-03-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-01-21 | 2022-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-03-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-01-21 | 2022-03-01 | N |
