Little Sisters of the Poor

In the surveyor’s words

From the most serious findings on record at Little Sisters of the Poor, in the surveyor’s own words.

• Actual harm, isolatedF689May 1, 2025

  Based on interview and record review the facility failed to properly transfer a resident (R1) using a mechanical lift during bedside care. This failure affected one resident (R1) causing R1 to sustain a fracture of the distal shaft of the fifth metatarsal and pain in left hand fifth metatarsal. Findings include: R1 has a diagnosis which includes but are not limited to unspecified abnormalities of gait and mobility and paralytic gait. R1 has a Brief Interview of Mental Status (BIMS) dated 03/17/25 documents that R1 has a BIMS score of 08 which indicates that R1 has some cognitive impairments. R1's Initial/Final Report to the surveying state agency dated 01/15/25 at 8:05 am documents in part: Date, Time, location of Injury: 01/12/2025, 3:50 pm, Residents bedroom. […]

• Actual harm, isolatedF689Aug 29, 2024

  Based upon observation, interview, and record review the facility failed to ensure that (R1's) care plan was congruent with the fall risk assessment, failed to implement fall prevention interventions and failed to provide supervision to three of three residents (R1, R2, R3) reviewed for falls. These failures resulted a laceration to the left lower leg from R1's 6/25/24 fall. These failures also resulted a laceration, abrasion, and bruises to the forehead, bridge of nose, and both arms along with a C1 fracture from R1's 7/13/24 fall. Findings include: 1.) The facility's fall incident log affirms R1 fell on [DATE] and 7/13/24. R1's (6/25/24) incident report states Unwitnessed Fall. Called to resident room by CNA (Certified Nursing Assistant). […]

• Actual harm, isolatedF689Oct 8, 2021

  Based on observation, interview and record review the facility failed to implement measures to supervise and maintain a safe environment to prevent falls for 2 of 3 residents (R1 and R2) in the sample of 7 reviewed for falls and safety. This failure affected R1 and R2 who had an unwitnessed fall. The facility failure resulted in R1 sustaining a right forearm [MEDICATION(S)] fracture of the distal radius and ulna and right hip intertrochanteric fracture with varus deformity; and R2 sustaining a right femur fracture. Findings include: 1. R1's medical record face sheet documents the date of initial admission as [DATE]. On [DATE] R1 had an unwitnessed fall. The Facility Incident Report for R1 dated [DATE] at 3:16 am shows the following: R1 was found on the floor next to R1's bed. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based on observation, interview, and record the facility failed to follow their policy and discard food items that were labeled with a used by date. This failure has the potential to affect all 44 residents in the facility who eat meals from the kitchen. Findings include: On 5/04/26 upon initial kitchen observation at 09:45 AM, walk-in cooler labeled #4 were observed with these items: corn beef with wrapper half open with use by date of 4/28/2026, and pepperoni (2) rolls with a used by date of 4/30/2026. The walk-in cooler labeled #3 were observed with bread with a used by date of 4/22/2026, (8) bags of Collard greens with a use by date of 4/30/2026, corn meal with used by date of 4/30/2026, seasoning oil with use by date of 4/10/2026, and cake mix with use by date 4/27/2026. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2025

  Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, c.) equipment used for food preparation not properly sanitized, and d.) dishwasher temperatures not reaching at least 160 degrees Fahrenheit during the wash cycle. These deficient practices have the potential to affect all 43 residents receiving food prepared in the facility kitchen. Findings include: On [DATE] at 9:39 AM during initial kitchen tour with V7 (Dietary Manager), the following food items were found in the dairy walk-in cooler: 1. […]