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Deficiency Records for Little Sisters of The Poor
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.
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? |
|---|---|---|---|---|
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-12-10 | 2025-01-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-12-10 | 2025-01-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-12-10 | 2025-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-12-10 | 2025-01-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-12-10 | 2025-01-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-12-10 | 2025-01-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-12-10 | 2025-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-12-11 | 2025-01-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-12-11 | 2025-01-09 | 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 | 2024-12-11 | 2025-01-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-12-11 | 2025-01-09 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-12-11 | 2025-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-12-11 | 2025-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-03 | 2024-11-08 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-10-03 | 2024-11-08 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-10-03 | 2024-11-08 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-10-03 | 2024-11-08 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2024-10-03 | 2024-11-08 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-10-03 | 2024-11-08 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-10-03 | 2024-11-08 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-10-03 | 2024-11-08 | Y |
| 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 |
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