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, widespreadF801Mar 30, 2023

  Based on staff interview it was determined the facility failed to have a full time certified dietary manager to oversee the operations in the dietary department. This was evident during a tour of the kitchen during the annual survey and had the potential to affect all residents. The findings include: On 3/22/23 at 9:03 AM a tour of the kitchen was conducted with the Director of Food Service, Staff #20. Staff #20 was asked if she was a certified dietary manager (CDM). Staff #20 stated, I have a pre CDM, but I still have to take the test. On 3/29/23 at 1:30 PM an interview was conducted with the Registered Dietician (RD). The RD stated she was only at the facility one day a week on Mondays. […]

• No harm, potential for more than minimal, widespreadF867Mar 30, 2023

  Based on documentation review and interview, it was determined the facility failed to have a quality assurance policy that had written procedures for quality assurance activities. This was evident during the annual survey and had the potential to affect all residents. The findings include: On 3/30/23 at 1:52 PM an interview with was conducted with Licensed Practical Nurse (LPN) #3 who oversaw quality assurance activities and Staff #31. LPN #3 described the items that were reported on in quality assurance meetings. The quality assurance and performance improvement program policy was reviewed with LPN #3 and Staff #31. The policy was six pages and documented the purpose, organization, authority, responsibilities, methodology, problem assessment, confidentiality, and evaluation. […]

• No harm, potential for more than minimal, patternF622Mar 30, 2023

  Based on medical record review and staff interview, it was determined that the facility failed to: 1) orient, prepare, and document a resident's preparation for a transfer to the hospital and 2) document that information was provided to the acute care facility when a resident was transferred there emergently. This was identified for 3 (Resident #9, #16, #4) of 3 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 3/23/23 at 9:17 AM an interview was conducted with Resident #9. Resident #9 was asked if h/she had been sent to the hospital recently. […]

• No harm, potential for more than minimal, patternF641Mar 30, 2023

  Based on observation, interview and medical record review, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#3, #6, #9, #2) of 14 records reviewed during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. […]

• No harm, potential for more than minimal, patternF656Mar 30, 2023

  Based on observation, medical record review, and staff interview it was determined that facility staff failed to develop and initiate comprehensive, resident centered care plans for residents residing in the facility. This was evident for 6 (Resident #3, #4, #5, #6, #9, #10) of 14 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. […]