Inspection visit
Inspection
15 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 15 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify
a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) for one out of three
residents (Resident R42).
Findings include:
The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health
condition that affects how your body turns food into energy. Most of the food you eat is broken down into
sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals
your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use
as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it
makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much
blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart
disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is
lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may
lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus
may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's.
The facility Change in Resident Condition or Status policy dated 11/6/23, stated if the resident has a
change in condition the resident's physician must be immediately notified. It was indicated the change in
health status and any intervention shall be documented in the medical record.
The facility Physician Notification policy dated 11/6/23, indicated that the facility will maintain
communication between the facility and the physician, regarding any changes that occur with residents. The
purpose of the policy is to ensure that all residents issues are addressed in a timely manner. The policy
states the physician must be notified for a change in condition and hypoglycemia.
The facility Diabetic Resident policy dated 11/6/23, indicated it is the facility policy to provide appropriate
medical and nursing care is provided to residents with diabetes. It was indicated if a resident experiences
hypoglycemia (below 70mg/dl). the physician and Director of Nursing (DON) must be notified.
Review of Resident R42's was admitted to the facility on [DATE].
Review of Resident R42's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment
of
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 17
Event ID:
396116
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
resident care needs) dated 8/9/23, indicated that he was admitted with diagnoses that included diabetes
(metabolic disorder impacting organ function related to glucose levels in the human body) and high blood
pressure.
Review of Resident R42's care plan dated 11/6/19, indicated the staff will check the resident's blood
glucose before meals and at bedtime with sliding scale coverage with Humalog.
Review of Resident R42's physician order dated 3/28/23, indicated to administer insulin subcutaneously via
insulin pen three times a day using blood glucose monitoring and the following protocol:
200-240=6 units
241-300=8 units
301-340=10 units
341 or greater =12 units and call the doctor
Review of Resident R42's October 2023 Medication Administration Treatment (MAR) record indicated
Resident R42's blood sugar was 63 on 10/14/23, at 5:30 p.m.
Review of Resident R42's clinical progress notes did not include physician notifications for the abnormal
glucose levels for 10/14/23.
Review of Resident R42's progress note dated 10/15/23, entered at 12:22 a.m. indicated the resident was
resting quietly and lethargic. It was documented the resident had an elevated blood pressure of 188/109
(normal blood pressure is less than 120/80), elevated heart rate of 139 beats per minute (normal pulse is
70 to 100 beats per minute), and an increased respiratory rate of 24 breaths per minute (normal respiratory
rate is between 12 to 20 breaths a minutes). Review of Resident R42's progress notes dated 10/15/23,
failed to indicate the resident's physician was notified of the resident's change in condition.
Review of Resident R42's progress note dated 10/15/23, entered at 8:20 a.m. indicated the resident's blood
sugar was 44. A further review of Resident R42's progress notes dated 10/15/23, failed to include
documentation that the physician was notified the resident's blood glucose was 44.
During an interview on 12/7/23, at 2:19 p.m. Registered Nurse (RN), Employee E5 stated if a resident had
low blood sugar and was lethargic, the Director of Nursing (DON) would be notified prior to the physician is
called.
During an interview on 12/7/23, at 2:26 p.m. RN, Employee E4 stated if a resident has a change in
condition the DON and physician must be notified and documented in the clinical record.
During an interview on 12/8/23, at 11:44 a.m. the DON confirmed the facility failed to notify a physician for
Resident R42's abnormal glucose levels on 10/14/23, change in condition that occurred on 10/15/23, and
low blood glucose of 44 on 10/15/23. The DON confirmed the facility failed to notify the physician for a
change in condition for one of three residents (Resident R42).
28 Pa. Code 201.14(a) Responsibility of licensee.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 2 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
28 Pa. Code 201.14(c)(e) Responsibility of licensee.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.18(b)(3) Management.
Residents Affected - Few
28 Pa. Code 201.20(b) Staff development.
28 Pa. Code 211.10(c) Resident care policies.
28 Pa. Code 211.10(d) Resident care policies.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 3 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it
was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's
status for two of twelve residents (Resident R26 and R43).
Residents Affected - Few
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing
Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs),
dated October 2023, indicated the following instructions:
-Section K0510: Nutritional Approaches, check all of the nutritional approaches that were performed in the
last 7 days; K0510C, mechanically altered diet - require change in texture of food or fluid (e.g. puree food,
thickened liquids).
Review of clinical record revealed that Resident R26 was admitted to the facility 7/5/21.
Review of Resident R26's MDS assessment dated [DATE], indicated diagnoses high blood pressure, renal
insufficiencies, and dysphagia (a condition with difficulty swallowing food or liquid).
-Section K0510C: Mechanically altered diet failed to indicate a check, while a resident in the last 7 days,
indicating this nutritional approach was not performed.
Review of Resident R26's physician order dated 7/8/21, indicated Regular/General diet, Mechanical Soft
textures, thin consistency, chopped meats per resident request.
Review of additional MDS assessments for Resident R26, dated 5/15/23, and 8/16/23, indicated that
Section K0510C: Mechanically altered diet was indicated with a check, while a resident in the last 7 days,
indicating the this nutritional approach was performed.
Review of Resident R43's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R43's MDS dated [DATE], indicated diagnoses of high blood pressure, insomnia
(trouble falling and/or staying asleep), and peripheral vascular disease (occurs when blood flow is restricted
to the tissue because of spasm or narrowing of the vessel.) It was indicated the resident was discharged to
a short-term general hospital.
Review of Resident R43's progress note dated 10/20/23, indicated the resident was discharged back to her
apartment.
During an interview conducted on 12/7/23, at 1:00 p.m., Resident Nurse Assessment Coordinator (RNAC)
Employee E2 confirmed that the facility failed to ensure that MDS assessments accurately reflect the
resident's status for two of twelve residents (Resident R26 and R43).
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 4 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical records, and staff interview it was determined that the facility failed to
provide interventions to treat abnormal glucose readings via a Capillary Blood Glucose (CBG) level and
provide treatment as ordered for one out of three residents (Resident R42).
Residents Affected - Few
Findings include:
The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health
condition that affects how your body turns food into energy. Most of the food you eat is broken down into
sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals
your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use
as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it
makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much
blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart
disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is
lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may
lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus
may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's.
The facility Physician Notification policy dated 11/6/23, indicated that the facility will maintain
communication between the facility and the physician, regarding any changes that occur with residents. The
purpose of the policy is to ensure that all residents issues are addressed in a timely manner. The policy
states the physician must be notified for a change in condition and hypoglycemia.
The facility Change in Resident Condition or Status policy dated 11/6/23, stated if the resident has a
change in condition the resident's physician must be immediately notified. It was indicated the change in
health status and any intervention shall be documented in the medical record.
The facility Diabetic Resident policy dated 11/6/23, indicated it is the facility policy to provide appropriate
medical and nursing care is provided to residents with diabetes. It was indicated if a resident experiences
hypoglycemia (below 70mg/dl) if conscious, give orange juice with sugar or glucose tablets. If unconscious,
place a spoonful of moistened sugar under the tongue. The facility policy stated to have sugar in some form
readily available in case of hypoglycemia and to check the emergency box for available medication.
Review of Resident R42's was admitted to the facility on [DATE].
Review of Resident R42's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment
of resident care needs) dated 8/9/23, indicated that he was admitted with diagnoses that included diabetes
(metabolic disorder impacting organ function related to glucose levels in the human body) and high blood
pressure.
Review of Resident R42's care plan dated 11/6/19, indicated the staff will check the resident's blood
glucose before meals and at bedtime with sliding scale coverage with Humalog. It was indicated staff will
re-apply the resident's Free Style Libre glucometer scanner to her arm every other week.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 5 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Review of Resident R42's physician order dated 3/28/23, indicated to administer insulin subcutaneously via
insulin pen three times a day using blood glucose monitoring and the following protocol:
Level of Harm - Minimal harm
or potential for actual harm
200-240=6 units
Residents Affected - Few
241-300=8 units
301-340=10 units
341 or greater =12 units and call the doctor
Review of Resident R42's physician order dated 10/13/23, indicated to apply a FreeStyle Lite Device (Blood
Glucose Monitoring Device) to alternating arms.
Review of Resident R42's October 2023 Treatment Administration Record (TAR) revealed the resident's
FreeStyle Lite Device was not reapplied as ordered. It was left blank and not signed off for completion.
Review of Resident R42's October 2023 Medication Administration Treatment (MAR) record indicated
Resident R42's blood sugar was 63mg/dl on 10/14/23, at 5:30 p.m.
Review of Resident R42's clinical progress notes did not include documentation of the interventions
implemented to address the resident's low blood sugar of 63mg/dl on 10/14/23.
During an interview on 12/8/23, at 11:44 a.m. the Director of Nursing (DON) stated that the facility failed to
document interventions that were implemented for the abnormal glucose levels on 10/14/23 and follow
physician orders as ordered for one of three residents (Resident R42).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 6 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based a
review of facility policy, clinical record review and staff interview, it was determined that the facility failed to
timely assess the nutritional status and develop an individualized care plan after an unplanned weight loss
for one resident (Resident R14), and failed to timely assess the nutritional status of one resident (Resident
R26).
Residents Affected - Few
Findings include:
Review of facility policy MDS, Completion/Error Corrections, dated 11/6/23, indicates the Minimum Data
Set (MDS) will be completed for each resident within fourteen (14) days of admission, annually, quarterly,
and whenever a significant change occurs in the resident's condition.
Review of facility policy Hydration and Nutrition, dated 11/6/23, indicates the nutrition and hydration status
of each resident is maintained as close to optimal levels as possible. The dietary plan of care and progress
note is written at least every ninety (90) days.
Review of facility policy Medical Nutritional Therapy Documentation, dated 11/6/23, indicates that
documentation of medical nutritional therapy (MNT) for each individual is the responsibility of the registered
dietitian nutritionist (RDN) with assistance as assigned to the nutrition support staff, as appropriate within
each professional's scope of practice and competency level. All documentation will be in accordance with
state and federal regulations, using facility-approved electronic health records and/or forms. MNT
Re-Assessment/Progress notes should be completed according to facility policy and state and federal
guidelines. Generally, progress notes are written at a minimum of every 90 days; and with each significant
change in status. Each time a re-assessment or progress note is completed, the care plan should be
updated.
Review of Resident R14's admission record indicated that she was admitted to the facility 4/14/16.
Review of Resident R14's Minimum Data Set (MDS) assessment (mandated assessment of a resident's
abilities and care needs) dated 11/3/23, indicated diagnoses of unspecified dementia (a group of symptoms
that affects memory, thinking and interferes with daily life), polymyalgia rheumatica (a syndrome
experienced as pain or stiffness), and Alzheimer's disease (a neurodegenerative disease that slowly erases
memory, thinking and behavior). Review of Section K0300: Weight Loss was coded with Yes, indicating a
loss of 5% or more in the last month or loss of 10% or more in last 6 months.
Review of Resident R14's weight record indicated the following weights:
5/1/23 118 pounds
10/2/23 120.3 pounds
11/1/23 114 pounds - a loss of 5.5% in one month
Review of Resident R14 clinical record failed to reveal any Medical Nutrition Therapy documentation for the
significant weight loss of 5.5% in one month that occur in 11/2023, captured by MDS dated [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 7 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Further review of Resident R14's clinical record failed to indicate that her care plan was updated to address
identified causes, goals, specific interventions, and time frame for monitoring for current significant loss in
weight.
Review of clinical record revealed that Resident R26 was admitted to the facility 7/5/21.
Residents Affected - Few
Review of Resident R26's MDS assessment dated [DATE], indicated diagnoses high blood pressure, renal
insufficiencies, and dysphagia (a condition with difficulty swallowing food or liquid).
Review of Resident R26's clinical record failed to reveal any Medical Nutritional Therapy documentation
since 8/9/23.
During an interview on 12/9/23, at 9:43 a.m., RNAC Employee E2 confirmed that there was no Registered
Dietitian Nutritionist from 10/30/23 until 11/14/23, and that the facility failed to timely assess the nutritional
status and develop an individualized care plan after an unplanned weight loss for one resident (Resident
R14), and failed to timely assess the nutritional status of one resident (Resident R26).
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.12(d)(1) Nursing services.
28 Pa. Code: 211.12(d)(3) Nursing services.
28 Pa. Code: 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 8 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, observations, resident records and staff interview it was determined that the facility
failed to accurately monitor the intake of a enteral feed for one out two residents (Resident R1).
Findings include:
The facility Tube Feeding policy reviewed on 11/6/23, indicated physician specifies the type of solution,
amount, and frequency and feedings are initiated and monitored by a licensed nurse. It stated the purpose
is to supply nutrition and hydration to residents unable to take liquid or mouth by normal means.
The facility Documentation in Medical Record policy dated 11/6/23, indicated each resident's medical
record shall contain an accurate representation of the actual experience of the resident and include enough
information to provide a picture of the resident's progress through complete, accurate, and timely
documentation.
Review of Resident R1's admission record indicated she was admitted on [DATE], with diagnoses that
included dysphagia (difficulty swallowing), constipation, and depression.
Review of Resident R1's MDS assessment dated [DATE], indicated that the diagnoses were current upon
review. Section KO510. Nutritional approaches indicated that Resident R1 had a feeding tube.
Review of Resident R1's care plan dated 6/16/23, indicated the resident had a feeding tube for feedings
and staff will administer two cal feeding (a liquid nutrition product for patients with volume intolerance or
fluid restriction) as ordered via feeding pump.
Review of Resident R1's physician orders dated 7/10/23, indicated to administer a total of 240 ml of two cal
formula at 80 ml every hour for three hours daily with water infusion of 50ml every hour while formula is
being administered, at bedtime.
Review of Resident R1's physician orders dated 7/10/23, indicated to administer a total of 160 ml of two cal
formula at 80 ml every hour for two hours daily with water infusion of 50ml every hour while formula is being
administered, three times a day.
Review of Resident R1's progress notes dated 10/25/23, indicated the resident is ordered to receive a total
of 720 ml of enteral feed formula.
Review of Resident R1's December 2023 Medication Administration Record (MAR), failed to include
documentation that Resident R1's ordered tube feed was administered at night, as ordered. It was left blank
and not signed off for completion on 12/2/23, and 12/3/23. Resident R1's total intake was marked
non-applicable and not documented on 12/4/23, 12/6/23, and 12/8/23.
Review of Resident R1's December 2023 Medication Administration Record (MAR), failed to include
documentation that Resident R1's ordered tube feed was administered at three times a day, as ordered. It
was documented on 12/1/23, the resident received 240ml of her tube feed instead of the ordered 160ml on
12/1/23, and 12/2/23, at 6:00 a.m., 12:00p.m., and 5:00p.m. It was documented the resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 9 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
received 130ml of tube feed instead of the ordered 160ml on 12/3/23, and 12/4/23,at 6:00 a.m. Resident
R1's total intake was marked non-applicable and not documented on 12/3/23, 12/4/23, and 12/6/23, and
12/8/23 at 5:00 p.m.
During an observation on 12/8/23, at 8:17 a.m. Resident R1's tube feed pump indicated she received a total
of 5240ml of her tube feed.
During an interview on 12/8/23, at 8:20 a.m. RN, Employee E4, confirmed the facility staff failed to reset the
tube feed pump and stated there was no way of knowing how much of the tube feed was administered to
Resident R1.
During an interview on 12/8/23, at 8:20 a.m. the Director of Nursing confirmed the facility failed to follow
physician orders and accurately monitor the intake of a enteral feed for one out two residents (Resident
R1).
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1) Nursing services.
28 Pa. Code: 211.12(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 10 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on a review of facility policy, facility's planned cycle menus, observations, and interviews with staff, it
was determined that the facility failed to develop therapeutic menu extensions to ensure a pre-planned
nutritionally adequate menu was developed for four of four weeks of their cycle menu.
Findings include:
Review of the facility's policy Menu Planning, dated 11/3/23, indicated that nutritional needs of individuals
will be provided in accordance with the established national standards adjusted for age, gender, activity
level and disability, through nourishing, well balanced diets. Regular and therapeutic menus will be written
by the facility's food and nutrition professional, in accordance with the facility's approved diet manual.
Review of facility's policy Therapeutic Diets, dated 11/3/23, indicated that the facility will provide a
therapeutic diet that is individualized to meet the clinical needs and desires of the patient/resident to
achieve outcomes/goals of care. Available therapeutic menus should coincide with the therapeutic diets on
the facility's menu extensions. The registered dietitian nutritionist (RDN) will approve all therapeutic diet
menu extensions.
Review of facility's policy Diets Available on Menu, dated 11/3/23, indicated the therapeutic diet orders that
will be offered are:
a. Regular (or General/House diet)
b. Regular/No Salt Packet
c. Mechanical Soft, Moist, minced
d. Pureed
e. Consistent Carbohydrate
f. Consistent Carbohydrate Puree
g. Other:
Review of facility provided document Diet Type Report, dated 12/7/23, included a listing of all diet orders in
the facility by resident, which revealed additional therapeutic diets ordered such as No Added Salt (NAS),
No Concentrated Sweets (NCS), and No Concentrated Sweets/Controlled Carbohydrates (NCS/CC).
Review of facility's planned 4 week cycle menu failed to indicate that therapeutic menu extensions were
developed for each therapeutic diet provided or available at the facility.
During an interview on 12/8/23, at 10:00 a.m., Food Service Director (FSD) Employee E3 confirmed that
the facility failed to develop therapeutic menu extensions to ensure a pre-planned nutritionally
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 11 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
adequate menu was developed for four of four weeks of their cycle menu.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 211.6(a) Dietary services.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 12 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0836
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure the facility is licensed under applicable State and local law and operates and provides services in
compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted
professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interviews, it was determined the Director of Nursing failed to follow
accepted standards of nursing practice.
Findings include:
28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection
211.12(d)(5), dated July 1, 2023, indicated general supervision, guidance and assistance for a resident in
implementing the resident's personal health program to assure that preventive measures, treatments,
medications, diet and other health services prescribed are properly carried out and recorded.
Review of the job description titled Director of Nursing (DON) dated 9/1/14, indicated the DON is
responsible for the standards of nursing practice. It was indicated the DON assures that nursing
documentation is informative, descriptive of care rendered and that is compliant with federal and state
regulations.
The facility Change in Resident Condition or Status policy dated 11/6/23, stated if the resident has a
change in condition the resident's physician must be immediately notified. It was indicated the change in
health status and any intervention shall be documented in the medical record.
The facility Physician Notification policy dated 11/6/23, indicated that the facility will maintain
communication between the facility and the physician, regarding any changes that occur with residents. The
purpose of the policy is to ensure that all residents issues are addressed in a timely manner. The policy
states the physician must be notified for a change in condition and hypoglycemia.
The facility Documentation in Medical Record policy dated 11/6/23, indicated each resident's medical
record shall contain an accurate representation of the actual experience of the resident and include enough
information to provide a picture of the resident's progress through complete, accurate, and timely
documentation.
Review of Resident R42's was admitted to the facility on [DATE].
Review of Resident R42's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment
of resident care needs) dated 8/9/23, indicated that she was admitted with diagnoses that included
diabetes (metabolic disorder impacting organ function related to glucose levels in the human body) and
high blood pressure.
A review of Resident R42's late entry progress note entered by the Director of Nursing (DON) dated
10/15/23, at 7:15 a.m. effective for 10/14/23, at 6:11 p.m. indicated she spoke with resident's doctor and
gave him an update and that the IV wasn't inserted until 3 pm. The rate of the IV fluids was increased to
200ml until the one liter is infused. Administer Narcan x1 and update him in a couple of hours.
A review of Resident R42's physician orders dated 10/14/23, failed to include an order to infuse the
resident's IV fluids at 200ml/hr.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 13 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0836
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A review of Resident R42's late entry progress note dated 10/15/23, at 7:20 a.m. effective for 10/14/23, at
8:45 p.m. stated the doctor was updated that she was more alert, blood sugar was 98. She was
complaining of pain when moved. He ordered Lidocaine patch to be applied near incision site of her right
leg. Staff to encourage thickened liquids.
Review of Resident R42's progress note dated 10/15/23, indicated at 12:30 a.m. the DON was updated on
the resident's change in condition. It was documented the DON was informed the resident had an elevated
pulse and blood pressure, lethargy and cough. It was indicated the DON informed the nurse that her pulse
was elevated due to anemia condition in the hospital and receiving Eliquis medication. Has had a buildup of
oxycodone medication and treated with Narcan (a drug that can temporarily reverse the potentially deadly
effects of opioid overdose during an emergency) on evening shift. It was documented the DON mentioned
to the nurse, the resident received normal saline IV fluids which increased resident's alertness. DON stated
doctor stated to keep giving nectar thick fluids.
During an interview on 12/7/23, at 2:19 p.m. Registered Nurse (RN), Employee E5 stated when a change in
condition occurs it is the facility's protocol to touch base with DON or Nursing Home Administrator, and
most of the time they notify physician. It was indicated all notification is documented in the progress note.
RN, Employee E5 stated the DON makes a quicker call and educated plan of action.
During an interview on 12/7/23, at 2;26 p.m. RN, Employee E4 stated if a resident has a change in
condition the DON is notified and they typically call the doctor.
During an interview on 12/8/23, at 11:44 a.m. the DON confirmed she failed to update Resident R42's
physician when the nurse informed her of the resident's change in condition on 10/15/23, at 12:30 a.m. The
DON stated sometimes she has the nurses document in their progress that she contacted the doctor. The
DON confirmed she failed to complete timely documentation for Resident R47 on 10/14/23. The DON
confirmed she failed to follow accepted standards of nursing practice.
28 Pa. Code: 201.13(b)(e) Issuance of license.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(d)(e)(1) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 14 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy, national and state guidance, clinical record review, observations, and staff interviews, it was
determined the facility failed to establish COVID policies updated to national standards, accurately track
COVID positive residents, and implement the proper precautions before they can spread to other persons
in the facility for one of three residents (Resident R32).
Residents Affected - Many
Findings include:
Review of the CDC COVID-19 Testing: What You Need to Know guidelines dated 9/25/23, indicated if a
resident's displays symptoms they should be tested immediately. If a resident does not have symptoms but
have been exposed to COVID-19, it was indicated to wait at least 5 full days after your exposure before
taking a test. If you are only going to take a single test, a Polymerase Chain Reaction (PCR) test will
provide a more reliable negative test result. It was indicated if you use an antigen test, a positive result is
reliable, but a negative test is not always accurate. If your antigen test is negative, take another antigen test
after 48 hours or take a PCR test as soon as you can. If your second antigen test is also negative, wait
another 48 hours and test a third time.
Review of the facility's Infection Prevention Policies dated 11/6/23, stated some guidelines are in place for
residents that test positive. It was indicated staff on a unit with a positive resident must wear masks until the
resident is clear to come out of their room. All care must be provided in the room.
Review of Resident R32's clinical record revealed that Resident R32 was admitted to the facility on [DATE],
with diagnoses that included asthma, dementia (a group of symptoms that affects memory, thinking and
interferes with daily life), and muscle weakness.
Review of Resident R32's Minimum Data Set (MDS - periodic assessment of resident's care needs) dated
11/13/23, revealed diagnoses were current.
Review of Resident R32's progress note dated 11/28/23, indicated the resident tested positive for COVID.
Review of Resident R32's physician order from 11/28/23, through 12/6/23, failed to include an order for
droplet precautions (Use of appropriate personal protective equipment (surgical mask always required,
apron, gown, gloves, and protective eyewear as appropriate.)
Review of the undated facility documented, titled COVID 19 Positive Cases July 2022-December 2023
indicated Resident R32 tested positive for COVID on 12/3/23.
During an interview on 12/7/2, at 9:12 a.m. Nurse Aide, Employee E6 confirmed Resident R32 did not have
isolation signage located outside the room.
During an interview on 12/06/23, at 1:42 p.m. Infection Preventionist, Employee E1 confirmed the facility
failed to accurately track COVID positive residents. Infection Preventionist, Employee E1 stated the facility
does not conduct outbreak testing and only tests residents if symptomatic.
During an interview on 12/6/23, at 2:59 a.m. the Director of Nursing (DON) confirmed the facility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 15 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
failed to establish COVID policies updated to national standards, accurately track COVID positive residents,
and implement the proper precautions before they can spread to other persons in the facility for one of
three residents (Resident R32).
28 Pa. Code: 201.14(a) Responsibility of licensee.
Residents Affected - Many
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 16 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
396116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Little Sisters of the Poor
1028 Benton Avenue
Pittsburgh, PA 15212
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policy, clinical record review and staff interview, it was determined that the facility failed to make
certain that pneumococcal vaccinations were administered in a timely fashion for one of five residents
(Resident R34).
Residents Affected - Few
Findings include:
Review of the facility policy dated 11/6/23, indicated the facility follows the most up to date administration
schedules for pneumococcal vaccines. Residents who have had Prevnar 13 should have a Prevnar 23 at
least one year later. After at least five years elapse since the first Prevnar 23, she is given one more dose of
Prevnar 23.
Review of the admission Record indicated that Resident R34 was admitted to the facility on [DATE].
Review of R34's Minimum Data Set (MDS-periodic assessment of care needs) dated 11/16/23, included
diagnoses of high blood pressure, peripheral vascular disease (a condition in which narrowed blood vessels
reduce blood flow to the limbs), and renal insufficiency (condition where the kidneys lose the ability to
remove waste and balance fluids).
Review of Resident R34's immunization record indicated Prevnar 13 was administered on 7/29/15.
Interview with Infection Preventionist Employee E1 on 12/8/23, at 11:01 a.m. indicated she had no
documentation of Resident R34 having received the Prevnar 23.
Review of Resident R34's Pneumococcal Immunization Informed Consent Dated 2/9/23, indicated the
resident's Power of Attorney consented to the resident receiving a pneumococcal vaccination.
During an interview on 12/8/23, at 11:30 a.m. the Infection Preventionist Employee E1 confirmed that the
facility failed to make certain that pneumococcal vaccinations were administered in a timely fashion for one
of five residents (Resident R34)
28 Pa. Code 211.5(f) Clinical records
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 17 of 17
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Back to topCitations
15 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F836 - Licensure
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0293GeneralS&S Cno actual harm
Have properly located and lighted "Exit" signs.
- 0291GeneralS&S Cno actual harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Cno actual harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Cno actual harm
Properly select, install, inspect, or maintain portable fire extinguishes.
FAQ · About this visit
Common questions about this visit
What happened during the December 8, 2023 survey of LITTLE SISTERS OF THE POOR?
This was a inspection survey of LITTLE SISTERS OF THE POOR on December 8, 2023. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LITTLE SISTERS OF THE POOR on December 8, 2023?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.