Inspection visit
Inspection
Citations
25 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F575 - The facility must post, in a form and manner accessible and understandable
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F946 - Compliance and ethics
Provide training in compliance and ethics.
F949 - Training Requirements
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
F945 - Infection control
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0311GeneralS&S Dpotential for harm
Have an enclosure around a vertical opening shaft.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
FAQ · About this visit
Common questions about this visit
What happened during the November 27, 2024 survey of LITTLE SISTERS OF THE POOR?
This was a inspection survey of LITTLE SISTERS OF THE POOR on November 27, 2024. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LITTLE SISTERS OF THE POOR on November 27, 2024?
Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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.