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, isolatedF689Apr 16, 2025

  Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R1). This failure created an immediate jeopardy situation for one of four residents (Resident R1). Findings include: Review of the facility Elopement Risk policy last reviewed 11/1/24, indicated all residents are assessed for elopement risk and those found to be at risk will have a resident care plan that addresses this issue. Policy is to attempt to prevent incidents of elopement and to provide for the safety and well-being of all residents. […]

• Actual harm, isolatedF689Aug 26, 2026

  Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance while preparing for a transfer from the wheelchair to the bed, which resulted in actual harm of a skin tear (a traumatic wound where the outer layers of skin are partially or completely separated from underlying tissue, usually caused by mechanical forces such as friction, shearing, or adhesive removal) for one of four residents (Resident R1).Findings include: Review of facility policy Accident/Incident Reports, Residents dated 11/10/25, indicated an accident is defined as an event that results in bodily injury or potential injury and/or causes a change in resident status. […]

• Actual harm, isolatedF600Jan 22, 2026

  Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm resulting in a scalp laceration, requiring three staples for one of three residents reviewed (Resident R35). Findings include: Review of the facility Abuse, Neglect, mistreatment, and Misappropriation of Resident Property policy dated 11/10/25, revealed neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• Actual harm, isolatedF689Jan 22, 2026

  Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to ensure that residents received adequate assistance to prevent accidents, which resulted in actual harm, requiring three staples for one of three residents reviewed (Resident R35). Findings include: Review of the facility Accident/Incident Reports, Residents policy dated 11/10/25, revealed the purpose of the policy is to ensure quality resident care and to prevent or treat complications. An accident is an event that results in bodily injury or potential injury and/or causes a change in a resident's status. […]

• Actual harm, isolatedF689Nov 27, 2024

  Based on review of facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision for a visually impaired resident during an activity involving a horse that resulted in the actual harm of the horse biting a resident and causing a fracture for one of six residents reviewed (Resident R17). Findings include: Review of facility policy Accident/Incident Reports, Residents dated 11/6/23, last reviewed 11/4/24, indicated an accident is an event that results in bodily injury or potential injury and/or causes a change in Resident status. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. […]