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.

• No harm, potential for more than minimal, widespreadF880Apr 30, 2026

  Based on interview, observation, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 8 of 8 residents. Additionally, the facility failed to maintain sanitary practices during food service, which had the potential to affect all 29 residents in the facility. The findings include:Review of the facility's policy titled, Hand Hygiene revised 08/29/2019, revealed under Purpose, hand hygiene was a simple and effective method for preventing the spread of pathogens, such as bacteria and viruses, which caused infections. […]

• No harm, potential for more than minimal, widespreadF568Jun 24, 2022

  Based on interview and record review, the facility failed to ensure residents and/or resident representatives received quarterly trust account statements for thirty-two (32) of thirty-two (32) residents. The findings include: A review of the facility policy, Residents' Personal Funds, revised 02/2022, revealed the facility provided statements upon request by the Resident or Resident Guarantor and mailed the statements at least quarterly with a Statement of Receipt. Additionally, the facility's Resident Services was responsible for reviewing the statements with the Residents who were capable of understanding the information. […]

• No harm, potential for more than minimal, widespreadF838Jun 24, 2022

  Based on interview, document review, and facility policy review, the facility failed to develop and implement a facility assessment. This had the potential to affect all residents. The findings include: A review of the policy titled, Developing Your Facility Assessment: Essential Components, dated 04/2017, indicated, Facility Assessment states a home must conduct and document a facility-wide assessment to define what resources are necessary to care for its Resident competently during day-to-day operations and emergencies. This facility assessment must be completed annually, or when significant changes to the resident population occur. […]

• No harm, potential for more than minimal, widespreadF865Jun 24, 2022

  Based on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a quality assurance performance improvement (QAPI) plan and program. This had the potential to affect all residents. The findings include: Review of facility policy, Quality Assurance and Performance Improvement Program (QAPI), dated 08/2017, revealed, the facility Medical Director and the Administrator were responsible for implementing the QAPI Program and organizing facility and medical staff functions to accomplish this program. Additionally, a Quality Assurance (QA)Committee coordinated a comprehensive QAPI Program involving medical, nursing, and other ancillary support services. […]

• No harm, potential for more than minimal, patternF812Apr 30, 2026

  Based on observation, interview, and policy review, the facility failed to maintain sanitary food handling practices during meal service affecting all residents who consumed food in the dining room. Observations during survey revealed staff failed to prevent potential cross-contamination during meal service through improper glove use, hand hygiene practices, and storage of serving utensils. The findings include:Review of the facility policy titled, Food Safety, dated 03/2017 and reviewed 09/2024, revealed it was the facility's policy to provide safe and sanitary storage, handling, and consumption of all food. […]