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.

• Immediate jeopardy, patternF812Aug 23, 2021

  Based on observation, interview, and record review, the facility failed to ensure unpasteurized eggs were fully cooked and prepared in a manner to prevent food borne illness. This resulted in an immediate jeopardy (IJ) situation for 1 of 1 residents (R19) who consumed the undercooked, unpasteurized eggs and 10 of 10 residents (R10, R13, R20, R25, R27, R29, R46, R47, R56, R157) who were identified to routinely consume undercooked eggs and had an increased risk of contracting a potentially life-threatening food borne illness. The facility also failed to ensure food was prepared, distributed, and served in accordance with safe food handling practices to prevent food borne illnesses and to store food in a manner to prevent biological, chemical, or physical contamination. […]

• Immediate jeopardy, isolatedF689Oct 3, 2024

  Based on interview and document review the facility failed to identify, comprehensively assess, implement individualized interventions for wandering, exit seeking behaviors, and elopement for 2 of 2 residents (R1, R2) who had a history of repeated exit seeking behaviors. The facility's failures resulted in immediate jeopardy (IJ) when R1 eloped from the facility, was found on a city street, and returned by a passerby. The immediate jeopardy began on [DATE] after R1 attempted elopement multiple times, the facility failed to complete comprehensive wandering/elopement assessments, monitoring system, and appropriate intervention resulting in R1's actual elopement on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2024

  Based on observation, interview, and record review the facility failed to ensure open refrigerated items were dated and covered. Furthermore, the facility failed to ensure expired items were removed from storage. This had the potential to impact all 32 residents residing in the facility. Findings include: An observation on [DATE] at 11:40 a.m., the main kitchen was reviewed. A walk-in refrigerator contained an open package of Hillshire Farm sliced turkey lunchmeat. The lunchmeat was wrapped in saran wrap and had no label or date. At 11:57 a.m., the walk-in dairy refrigerator was reviewed. The refrigerator contained 4 half gallons of [NAME] 2% milk. The best by date for all 4 containers was [DATE]. Dietary aide (DA)-A verified the expired milk and stated they should be thrown away. […]

• No harm, potential for more than minimal, widespreadF837Oct 3, 2024

  Based on interview and document review, the facility's governing body failed to establish and implement policies regarding the management and operation of the facility and further failed to ensure the administrator reported to and was held accountable to the governing body. This had to effect all current and future residents residing in the facility. Findings include: Policies: During a review of facility policies, the facility was unable to provide a copy of numerous requested policies which included: policy on physician visits, including frequency; policy on emergency physician care; policy on physician delegation of tasks; policy on physician delegation of dietary orders; policy on governing body; policy on communication between administrator and governing body; policy on… […]

• No harm, potential for more than minimal, widespreadF838Oct 3, 2024

  49338 Based on interview and document review, the facility failed to ensure the Facility Assessment (FA) was complete and included an evaluation of the resident population and its needs using evidence-based data driven methods, the competencies and skill sets for all personnel necessary to provide that care, information on staffing levels needed based on the resident population, a plan for maximizing recruitment and retention of direct care staff, and all contracted services required to meet resident needs. The facility further failed to ensure the FA was conducted with input from all necessary individuals. […]