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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?
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

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