Inspection visit
Inspection
25 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 25 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of facility policy, observations, and resident and staff interviews, it was determined that the facility
failed to provide care in a manner and environment that promotes and maintains quality of life by failing to
allow a resident to smoke at requested times for one of three residents reviewed (Resident R17).
Findings include:
Review of facility policy Residents' [NAME] of Rights dated 11/6/23, last reviewed 11/4/24, indicated the
Resident has the right to a dignified existence that will provide and maintain a supportive environment to
promote self-esteem and personal dignity and to ensure that the Resident and civil rights are respected
and protected.
Review of facility policy Smoking dated 11/6/23, last reviewed 11/4/24, indicated residents who are
determined by assessment that they are in need of supervision while smoking will be provided supervised
smoking breaks in the appropriate designated smoking area. Resident may be supervised by a facility
employee, family member and/or volunteer as assigned.
Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE].
Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24,
indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance
with personal care, and legal blindness. Section B - Hearing, Speech, and Vision, Question B1000 Vision,
indicated Resident R17 was coded 4 severely impaired, no vision or sees only light, colors or shapes; eyes
do not appear to follow objects.
Review of Resident R17's care plan dated 2/3/20, indicated staff or volunteer will transfer her outside via
wheelchair to smoking area to smoke, and whomever goes with her will make sure that she knows when to
flick the cigarette or extinguish it.
Review of progress note dated 8/20/24, stated, Resident R17 had therapy this evening. Remains in bed
lying flat. Taking medications while with regular cola. Requested Tylenol with codeine and Ibuprofen this
evening. Respirations easy and unlabored. Skin pink and warm. Resident R17 requested to go outside to
smoke multiple times this evening, stated a cigarette is the only thing that will help me. Resident R17 was
not taken outside on the evening shift.
During an interview on 11/25/24, at 11:22 a.m. Resident R17 stated, I only go out to smoke when
(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)
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Facility ID:
If continuation sheet
Page 1 of 33
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
11/27/2024
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 0550
Level of Harm - Minimal harm
or potential for actual harm
someone can take me and they don't always have enough help. More likely than not, like today, they don't
have enough help. Usually someone from Activities will take me, but she's not here today, she doesn't work
every day, and she can't take me if there is an activity scheduled. Sometimes a volunteer will take me out. I
only spend about 15 minutes outside. I would like to be able to go outside to smoke at least once a day, that
would be more than wonderful, I wouldn't dream of asking for more than once a day.
Residents Affected - Few
During an interview on 11/26/24, at 11:40 a.m. Resident R17 stated, I did not get to smoke yesterday. A
volunteer is here today who could take me but I think I may have missed him this morning because I had a
care conference and a therapy session. I think the last time I went out to smoke was on Friday [11/22/24].
During an interview on 11/27/24, at 10:37 a.m. Resident R17 stated, I was able to go outside to smoke
once yesterday because there was a volunteer here. It is psychologically important for me to be able to go
outside to smoke because I'm blind, my hip is broken, I'm sort of like a rat stuck in this room.
During an interview on 11/27/24, at 11:13 a.m. the Assistant Director of Nursing (ADON) Employee E2
stated, The smoking process is that Resident R17 will initiate when she wants to go smoke, she'll ask.
There are only a few staff members who smoke who want to take her, the non-smoking staff don't want to
take her and get the secondhand smoke, so unfortunately, depending on who is working, she doesn't get to
go every day.
During an interview on 11/27/24, at 11:13 a.m. the ADON Employee E2 confirmed that the facility failed to
provide care in a manner and environment that promotes and maintains quality of life by failing to allow a
resident to smoke at requested times for one of three residents reviewed (Resident R17).
Pa Code: 201.29(j) Resident Rights
FORM CMS-2567 (02/99)
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Event ID:
Facility ID:
396116
If continuation sheet
Page 2 of 33
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
11/27/2024
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 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident, and staff interviews, it was determined that the facility failed to determine the ability
to self-administer medications for one of three residents (Residents R24).
Residents Affected - Few
Findings include:
Review of the facility policy Medication Administration dated 11/6/23, last reviewed on 11/4/24, indicated
remain with resident to ensure that medication is swallowed.
Review of the admission record indicated Resident R24 was admitted to the facility on [DATE].
Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/7/24,
indicated the diagnoses of hypertension (high blood pressure), hyponatremia (low sodium in the blood),
and hyperlipidemia (high fat in the blood).
Review of Resident R24's physician orders failed to include medication self-administration.
Review of Resident R24's care plan failed to include interventions for medication self-administration.
Review of Resident R24's clinical record indicated the absence of a Self-Administration of Medication
Assessment.
Observation on 11/25/24, at 9:04 a.m. Resident R24 was sitting in her wheelchair in her room. A medication
cup containing assorted pills were noted on her overbed table. Registered Nurse (RN) Employee E5
entered the room, picked up the medication cup with assorted pills on the overbed table and stated, they
are her morning medications, she likes them in her room and exited the room with the medication cup of
assorted pills.
During an interview on 11/25/24, at 9:09 a.m. RN Employee E5 stated I don't believe she has an order to
keep them in her room, it depends on the medication that it was and confirmed that Resident R24's
morning medications were left in the room on the overbed table.
During an interview on 11/26/24 at 1:40 p.m. the Director of Nursing stated, there is no policy on medication
self-administration, there are no residents in the facility who do, medications should never be left at the
bedside, and confirmed that the facility failed to determine the ability to self-administer medications for one
of three residents (Residents R24).
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.
28 Pa. Code: 211.9(a)(1) Pharmacy services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 3 of 33
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
11/27/2024
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 0575
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on observations and staff interview it was determined that the facility failed to have required postings
for the Medicaid Fraud Control Unit for the facility.
Residents Affected - Some
Findings include:
Observations on the nursing care units on the First and Second Floor bulletin boards failed to include
information for the Medicaid Fraud Control Unit throughout the survey from 11/25/24, through 11/27/24.
During an observation and interview on 11/27/24, at 11:10 a.m. The Director of Nursing confirmed that the
facility failed to post information about the Medicaid Fraud Control Unit.
28 Pa. Code: 201.14(a)Responsibility of licensee.
28 Pa. Code: 201.18e Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 4 of 33
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
11/27/2024
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 0577
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, Group interview, and staff interview, it was determined that the facility failed to
ensure that the Department of Health Survey Results were readily accessible to residents and visitors, and
failed to post notice of the availability of the results on two of two Nursing Floors. (First Floor, and Second
Floor)
Residents Affected - Some
Findings Include:
Observations on the nursing care units on the First and Second Floor bulletin boards failed to include
information for the Department of Health Survey results throughout the survey from 11/25/24, through
11/27/24.
During a group interview on 11/26/24, at 9:59 a.m. ten out of ten residents were unaware of the location
where the survey results binder would be located and available to review.
During an observation and interview on 11/27/24, at 11:10 a.m. The Director of Nursing was able to locate
two Department of Health Survey Results Binders that were out of sight, as they were inside of desks on
the First Floor and Second Floor, and confirmed that the facility failed to post notice of availability of these
results on two of two Nursing Floors.
28 Pa. Code 201.14 (a) Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 5 of 33
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
11/27/2024
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, and staff interview, it was determined that the facility failed to maintain a safe homelike
environment in one of four nursing units (St. [NAME]).
Findings include:
During an observation of resident room [ROOM NUMBER] on 11/25/24, at 1:01 p.m. it was noted that the
door handle was missing, and an exposed, sharp piece of metal was sticking out from the mount where the
handle would be placed.
During an interview on 11/27/24, at 11:17 a.m. the Director of Nursing (DON) confirmed that the handle
was missing from the door of resident room [ROOM NUMBER] and an exposed, sharp piece of a metal
was sticking out from the mount where the handle would be placed.
During an interview on 11/27/24, at 11:17 a.m. the DON confirmed that the facility failed to maintain a safe
homelike environment in one of four nursing units (St. [NAME]).
28 Pa. Code: 201.18(b)(3)(e)(1) Management.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 207.2(2) Administrator's Responsibility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 6 of 33
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
11/27/2024
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 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, resident grievances for 12 months, and resident and staff interviews, it was
determined that the facility failed to ensure resident grievances were addressed timely for one of two
grievances reviewed.
Findings include:
Review of facility policy Grievance dated 11/6/23, last reviewed 11/4/24, indicated the Home will ensure
prompt resolution to all grievances, keeping the Resident and Resident Representative informed throughout
the investigation and resolution process.
Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE].
Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/24,
indicated diagnoses of high blood pressure, respiratory failure (a condition where the lungs cannot get
enough oxygen into the blood), and shortness of breath.
Review of a facility Grievance or Complaint Form indicated Resident R15 filed a grievance on 7/8/24.
There was no documentation available that the facility investigated and addressed Resident R15's
grievance until 11/8/24.
During an interview on 11/25/24, at 1:27 p.m. Resident R15 stated, I don't think they addressed it right
away. I can't remember exactly when it happened, but I think it took a little bit of time for the paperwork.
During an interview on 11/26/24, at 1:12 p.m. the Director of Nursing and the Nursing Home Administrator
confirmed that the facility failed to ensure resident grievances were addressed timely for one of two
grievances reviewed.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(e)(1) Management.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 PA Code: 201.29(j) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 7 of 33
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
11/27/2024
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 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, and staff interview it was determined that the facility failed to make certain that the
necessary resident information was communicated to the receiving health care provider for two of two
residents with facility-initiated transfers (Resident R17 and R35).
Findings include:
Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE].
Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24,
indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance
with personal care, and legal blindness.
Review of Resident R17's clinical record revealed that the resident was transferred to the hospital on
[DATE].
Review of Resident R17's clinical record revealed no documented evidence that the facility had
communicated specific information to the receiving health care provider for the residents transferred and
expected to return, which included the resident's care plan goals, advanced directive information, specific
instructions for ongoing care, resident representative information, and all information necessary to meet the
resident's specific needs at the receiving facility.
Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE].
Review of Resident R35's MDS dated [DATE], indicated diagnoses of high blood pressure, reduced
mobility, and weakness.
Review of Resident R35's clinical record revealed that the resident was transferred to the hospital on
[DATE].
Review of Resident R35's clinical record revealed no documented evidence that the facility had
communicated specific information to the receiving health care provider for the residents transferred and
expected to return, which included the resident's care plan goals, advanced directive information, specific
instructions for ongoing care, resident representative information, and all information necessary to meet the
resident's specific needs at the receiving facility.
During an interview on 11/26/24, at 11:21 a.m. the Assistant Director of Nursing (ADON) Employee E2
confirmed that there was no evidence that the necessary information was communicated to the receiving
health care institution or provider upon transfer for two out of two residents sampled with facility-initiated
transfers (Residents R17 and R35).
28 Pa. Code 201.29 (a)(c.3)(2) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 8 of 33
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
11/27/2024
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, and staff interview, it was determined that the facility failed to notify the
resident/resident representative and/or the representative of the Office of the State Long-Term Care
Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer
or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name,
address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman
for two of two resident records reviewed (Resident R17 and R35)
Findings Include:
Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE].
Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24,
indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance
with personal care, and legal blindness.
Review of Resident R17's clinical record revealed that the resident was transferred to the hospital on
[DATE].
Review of Resident R17's clinical record, the facility failed to include documented evidence that the facility
provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization
on 11/16/24.
Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE].
Review of Resident R35's MDS dated [DATE], indicated diagnoses of high blood pressure, reduced
mobility, and weakness.
Review of Resident R35's clinical record revealed that the resident was transferred to the hospital on
[DATE].
Review of Resident R35's clinical record, the facility failed to include documented evidence that the facility
provided a written transfer notification to the resident/resident representative and or Office of Long-Term
Care Ombudsman for the hospitalization on 11/22/24.
During an interview on 11/26/24, at 11:21 a.m. the Assistant Director of Nursing (ADON) Employee E2
confirmed that the facility failed to notify the resident/resident representative and or the representative of
the Office of the State Long-Term Care Ombudsman of resident transfers in writing or two out of two
residents (Residents R17 and R35).
28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 9 of 33
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
11/27/2024
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify
the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a
bed for an agreed upon rate during a hospitalization) for two of two resident hospital transfers (Resident
R17, and R35).
Findings Include:
Review of the facility policy Bed Hold and Return dated 11/4/24, and previously dated 11/6/23, indicated
that the facility will provide the resident and resident representative a written notice which specifies the
duration of the bed-hold policy at the time of transfer for hospitalization or therapeutic leave.
Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE].
Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24,
indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance
with personal care, and legal blindness.
Review of Resident R17's clinical record revealed that the resident was transferred to the hospital on
[DATE].
Review of Resident R17's clinical record failed to include documented evidence that the resident or the
resident's representative were provided with written information about the facility's bed hold policy at the
time of the transfer to the hospital on [DATE].
Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE].
Review of Resident R35's MDS dated [DATE], indicated diagnoses of high blood pressure, reduced
mobility, and weakness.
Review of Resident R35's clinical record revealed that the resident was transferred to the hospital on
[DATE].
Review of Resident R35's clinical record failed to include documented evidence that the resident or the
resident's representative were provided with written information about the facility's bed hold policy at the
time of the transfer to the hospital on [DATE].
During an interview on 11/26/24, at 11:21 a.m. the Assistant Director of Nursing (ADON) Employee E2
confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold
policy for Resident R17 and R35.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 10 of 33
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
11/27/2024
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 record review, and staff interviews, it was determined that the facility failed to
make certain that residents were provided appropriate treatment and care by failing to implement the
facility's hypoglycemia (low blood sugar) protocol, failing to document appropriate hypoglycemia
interventions, failing to notify the physician of a resident's refusal of weekly weights, and failing to follow
physicians orders for one of five residents reviewed (Resident R21).
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 mg/dL (milligrams per deciliter). If left untreated, hypoglycemia may
lead to weakness, confusion, unconsciousness, arrhythmias and even death.
Review of facility policy Hypoglycemia dated 11/6/23, last reviewed 11/4/24, indicated residents
experiencing hypoglycemia are treated according to current standards of practice unless contraindicated by
a physician order. Staff treating a conscious resident who is symptomatic or has a blood sugar less than
seventy (70) should administer a glass of juice with two added packets of sugar or Glucose gel fifteen (15)
milligrams.
Review of the facility's Registered Nurse (RN) job description indicated the RN will administer and
document prescribed medications/treatments accurately and timely and in compliance with
policies/procedures.
Review of the facility's Licensed Practical Nurse (LPN) job description indicated the LPN will administer and
document prescribed medications/treatments accurately and timely and in compliance with
policies/procedures.
Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE].
Review of Resident R21's MDS dated [DATE], indicated diagnoses of diabetes, hyperlipidemia (high levels
of fat in the blood), and heart failure (a progressive heart disease that affects pumping action of the heart
muscles).
Review of a physician order dated 12/13/23, indicated to use a FreeStyle Libre 2 Reader Device
(Continuous Blood Glucose System Receiver) apply to sensor topically four times a day related to diabetes.
Review of Resident R21's vitals records for October 2024, indicated the following blood glucose
measurements:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 11 of 33
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
11/27/2024
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
11/1/24 at 9:07 a.m. 59 mg/dL
Level of Harm - Minimal harm
or potential for actual harm
11/1/24 at 10:00 p.m. 64 mg/dL
11/4/24 at 8:42 a.m. 59 mg/dL
Residents Affected - Few
11/11/24 at 7:50 a.m. 61 mg/dL
11/17/24 at 7:08 a.m. 66 mg/dL
Review of Resident R21's progress notes from 11/1/24, through 11/27/24, failed to include documentation
that the facility's hypoglycemia protocol was implemented for Resident R21's abnormal blood glucose
readings on the dates listed above.
Review of a progress note dated 11/8/24, completed by LPN Employee E16 stated, Residents blood sugars
have been running low in the morning. Having to give her OJ (orange juice) with sugar. This morning at 4
a.m. she was 54. Had to give her OJ with sugar and glucose tablets crushed in pudding. Got blood sugar up
to 110. She is alert, oriented and responsive.
Review of a progress note dated 11/18/24, completed by RN Employee E17 stated, Resident's blood
glucose at 6 a.m. was 60; Resident presented asymptomatic for hypoglycemia and skin was warm and dry
to touch. Resident was easy to awaken and was alert upon awakening. Resident was given 120 milliliters
OJ with 3 sugar packets, consumed all. Resident has a frequent pattern of blood glucose levels quickly
dropping in the early morning hours. Resident states she consumed all of her evening snack offered.
Repeat blood glucose at 6:30 a.m. was 82. Follow up with physician is suggested to review insulin dosing
as pattern is frequently occurring.
Review of a progress note dated 11/23/24, completed by RN Employee E5 stated, Residents blood sugar
this morning was 53. OJ with 5 sugars given and blood sugar 127 at 6 a.m.
During an interview on 11/27/24, at 12:34 p.m. the Director of Nursing (DON) confirmed that the facility
failed to implement the facility's hypoglycemia protocol and failed to document appropriate hypoglycemia
interventions for Resident R21 on the dates listed above.
Review of a physician order dated 5/22/23, indicated to weigh Resident R21 with bath every evening shift
every Monday.
Review of Resident R21's August 2024 Medication Administration Record (MAR) indicated Resident R21
refused to be weighed on 8/5/24, and 8/26/24.
Review of Resident R21's progress notes from 8/1/24, to 8/31/24, failed to include documentation that the
physician was notified of Resident R21's weight refusals on 8/5/24, and 8/26/24.
Review of Resident R21's September 2024 MAR indicated Resident R21 refused to be weighed on 9/2/24,
9/9/24, 9/16/24, 9/23/24, and 9/30/24.
Review of Resident R21's progress notes from 9/1/24, to 9/30/24, failed to include documentation that the
physician was notified of Resident R21's weight refusals on 9/2/24, 9/9/24, 9/16/24, 9/23/24, and 9/30/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 12 of 33
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
11/27/2024
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
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident R21's October 2024 MAR indicated Resident R21 refused to be weighed on 10/7/24,
10/14/24, and 10/28/24.
Review of Resident R21's progress notes from 10/1/24, to 10/31/24, failed to include documentation that
the physician was notified of Resident R21's weight refusals on 10/7/24, 10/14/24, and 10/28/24.
Residents Affected - Few
During an interview on 11/27/24, at 12:34 p.m. the DON confirmed that the facility failed to notify the
physician of Resident R21's refusal of ordered weekly weights.
Review of a physician order dated 12/13/23, indicated to administer Metolazone 2.5 mg (milligrams) give
one tablet by mouth as needed for weight gain above 240 pounds, give 30 minutes before morning Lasix
dose.
Review of Resident R21's Weight Summary indicated the following weights:
9/3/24 - 221 pounds
9/20/24 - 222.5 pounds
10/6/24 - 220 pounds
10/21/24 220 pounds
10/29/24 - 220 pounds
Review of Resident R21's September 2024 MAR indicated Resident R21 was administered Metolazone 2.5
mg on 9/7/24, at 7:00 a.m. Resident R21's weight was documented as 221 pounds on 9/3/24.
Documentation failed to indicate Resident R21 had a weight gain above 240 pounds.
Review of Resident R21's October 2024 MAR indicated Resident R21 was administered Metolazone 2.5
mg on 10/5/24, at 7:00 a.m. Resident R21's weight was documented as 222.5 pounds on 9/20/24.
Documentation failed to indicate Resident R21 had a weight gain above 240 pounds.
During an interview on 11/27/24, at 12:34 p.m. the DON confirmed that the facility failed to follow a
physician order for Resident R17.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 201.29(a) Resident Rights
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 13 of 33
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
11/27/2024
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
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, observations, interviews, and clinical record review, it was determined that the
facility failed to provide appropriate respiratory care for four of seven residents (Residents R15, R25, R27,
and R29).
Residents Affected - Some
Findings include:
Review of facility policy Oxygen Nasal Cannulas, Face Mask and Nebulizer Set Ups Protocol dated
11/6/23, last reviewed 11/4/24, indicated the nasal cannulas, face masks, and nebulizer set ups are
changed routinely to decrease chance of infections. The date will be written on tape and applied to the
tubing.
Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE].
Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/24,
indicated diagnoses of high blood pressure, respiratory failure (a condition where the lungs cannot get
enough oxygen into the blood), and shortness of breath.
Review of a physician order dated 1/16/24, indicated to administer oxygen via nasal cannula (a lightweight
tube placed in the nostrils to deliver oxygen) to maintain pulse oximeter above 92% as needed at 2 liters
per minute every shift.
Review of a physician order dated 1/17/24, indicated to change oxygen tubing every night shift every
Wednesday for protocol.
Review of Resident R15's care plan dated 2/28/23, indicated staff will change oxygen tubing weekly and
humidification bottle monthly when in use.
During an observation on 11/25/24, at 10:59 a.m. Resident R15 was observed receiving oxygen via a nasal
cannula. No date was present on the nasal cannula tubing.
During an interview on 11/25/24, at 11:04 a.m. Registered Nurse (RN) Employee E1 confirmed there was
no date present on Resident R15's nasal cannula tubing and that the facility failed to provide appropriate
respiratory care.
Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE].
Review of Resident R25's clinical diagnosis sheet dated 6/22/24, indicated the diagnosis of peripheral
vascular disease (PVD- causes a reduced blood flow to extremities), diabetes (high sugar in the blood), and
hypothyroidism (thyroid gland doesn't make enough hormone).
Review of Resident R25's physician order dated 10/26/24, indicated to administer oxygen via nasal cannula
at 2 liters per minute for shortness of breath and to maintain pulse oximeter above 92% as needed every
shift.
Review of Resident R25's physician order dated 5/13/24, indicated to change oxygen tubing every night
shift every Tuesday for protocol.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 14 of 33
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
11/27/2024
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 0695
Level of Harm - Minimal harm
or potential for actual harm
During an observation on 11/25/24, at 9:54 a.m. Resident R25 was observed receiving oxygen via a nasal
cannula. No date was present on the nasal cannula tubing.
During an interview on 11/25/24, at 9:56 a.m. RN Employee E5 confirmed there was no date present on
Resident R25's nasal cannula tubing and that the facility failed to provide appropriate respiratory care.
Residents Affected - Some
Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE].
Review of Resident R27's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure),
diabetes, and hyperlipidemia (high fats in the blood).
Review of Resident R27's physician order dated 7/22/24, indicated to administer oxygen via nasal cannula
at 2 liters per minute continuously.
Review of Resident R27's physician order dated 7/22/24, indicated to change oxygen tubing every night
shift every Tuesday for protocol.
Review of Resident R27's care plan dated 1/9/23, indicated staff will change oxygen tubing weekly and
humidification bottle monthly when in use.
During an observation on 11/25/24, at 9:48 a.m. Resident R27 was observed receiving oxygen via a nasal
cannula. No date was present on the nasal cannula tubing.
During an interview on 11/25/24, at 9:53 a.m. RN Employee E5 confirmed there was no date present on
Resident R27's nasal cannula tubing and that the facility failed to provide appropriate respiratory care.
Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE].
Review of Resident R29's MDS dated [DATE], indicated diagnoses of hypertension, diabetes, and
hyperlipidemia.
Review of Resident R29's physician order dated 7/13/24, indicated to administer oxygen via nasal cannula
to maintain oxygen saturation greater than 92% as needed.
Review of Resident R29's physician order dated 1/23/24, indicated to change oxygen tubing weekly and
humidifier monthly when in use.
Review of Resident R29's care plan dated 1/24/23, indicated staff will change oxygen tubing weekly and
humidification bottle monthly when in use.
During an observation on 11/25/24, at 9:19 a.m. Resident R29's oxygen concentrator with tubing was noted
in her room the oxygen tubing failed to be labeled with a date.
During an interview on 11/25/24, at 9:24 a.m. RN Employee E5 confirmed there was no date present on
Resident R29' s oxygen tubing and that the facility failed to provide appropriate respiratory care.
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 15 of 33
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
11/27/2024
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 0695
28 Pa. Code: 211.10(c)(d) Resident care policies.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code: 211.11 (a)(c)(d) Resident care plan.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 16 of 33
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
11/27/2024
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of facility policy, clinical record review, and staff interview, it was determined that the
facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet resident
needs and the risks associated with bedrail usage for five of five residents (Residents R17, R21, R27, R29,
and R30).
Findings include:
Review of facility policy Bed Rail Use dated 11/6/23, last reviewed 11/4/24, indicated the resident's
condition is reassessed at least annually or for a change in condition by Physical Therapy to determine the
need for continuing use of half-length rails.
Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE].
Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24,
indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance
with personal care, and legal blindness.
Review of a physician order dated 9/9/19, indicated top two side rails up when in bed to enhance mobility
due to blindness.
Review of Resident R17's care plan dated 5/28/23, indicated staff will have top two side rails up when she
is in bed to aide in mobility.
During an observation on 11/25/24, at 9:11 a.m. Resident R17 was observed lying in bed with two top side
rails present on her bed.
Review of Resident R17's clinical record revealed a PCE - Siderails Assessment dated 9/9/19, and failed to
reveal any additional completed siderail assessments for Resident R17.
During an interview on 11/26/24, at 2:55 p.m. the Director of Nursing (DON) confirmed Resident R17 had
no additional siderail assessments completed.
Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE].
Review of Resident R21's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia
(high levels of fat in the blood), and need for assistance with personal care.
Review of a physician order dated 5/15/23, indicated top two side rails up to aide in mobility and transfer.
Review of R21's care plan dated 5/15/23, indicated staff will have top two side rails up when in bed to aide
in mobility and transfer.
During an observation on 11/25/24, at 9:05 a.m. top two side rails were present on Resident R21's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 17 of 33
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
11/27/2024
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 0700
bed.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident R21's clinical record revealed a PCE - Siderails Assessment dated 4/18/22, and failed
to reveal any additional completed siderail assessments for Resident R21.
Residents Affected - Some
During an interview on 11/26/24, at 2:55 p.m. the DON confirmed Resident R21 had no additional siderail
assessments completed.
Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE].
Review of Resident R27's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure),
diabetes (high sugar in the blood) and hyperlipidemia.
Review of Resident R27's physician order dated 3/30/22, indicated top two side rails up when in bed to aide
in mobility.
Review of Resident R27's care plan dated 6/29/23, indicated staff will have top two side rails up when she
is in bed to aide in mobility and transfer.
During an observation on 11/26/24, at 1:00 p.m. Resident R27's bed was made, and the two top side rails
were present on the bed in the down position.
Review of Resident R27's clinical record revealed a PCE - Siderails Assessment dated 4/18/22, and failed
to reveal any additional completed siderail assessments for Resident R27.
During an interview on 11/26/24, at 2:55 p.m. the DON confirmed Resident R27 had no additional siderail
assessments completed.
Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE].
Review of Resident R29's MDS dated [DATE], indicated diagnoses of hypertension, diabetes, and anemia
(low iron in the blood).
Review of Resident R29's physician order dated 1/23/23, indicated top two side rails up when in bed to aide
in mobility and transfer.
Review of Resident R29's care plan dated 7/24/23, indicated two top side rails up when in bed.
During an observation on 11/26/24, at 1:12 p.m. Resident R29's bed was made, and the two top side rails
were present on the bed in the down position.
Review of Resident R29's clinical record revealed a PCE - Siderails Assessment dated 2/20/23, and failed
to reveal any additional completed siderail assessments for Resident R29.
During an interview on 11/26/24, at 2:55 p.m. the DON confirmed Resident R29 had no additional siderail
assessments completed.
Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 18 of 33
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
11/27/2024
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident R30's MDS dated [DATE], indicated diagnoses of hyperlipidemia, dementia
(progressive loss of intellectual functioning) and osteoarthritis (joint disease that causes pain, swelling and
stiffness).
Review of Resident R30's physician order dated 1/8/19, indicated both upper side rails used when in bed to
aide in mobility due to osteoarthritis.
Review of Resident R30's care plan dated 1/23/19, indicated both upper side rails used when in bed to aide
in mobility due to osteoarthritis.
During an observation on 11/26/24, at 12:55 p.m. Resident R30's bed was made, and the two top side rails
were present on the bed in the down position.
Review of Resident R30's clinical record revealed a PCE - Siderails Assessment dated 1/8/19, and failed to
reveal any additional completed siderail assessments for Resident R30.
During an interview on 11/26/24, at 2:55 p.m. the DON confirmed Resident R30 had no additional siderail
assessments completed.
During an interview on 11/26/24, at 2:55 p.m. the DON confirmed that the facility failed to conduct ongoing
accurate assessments to ensure that bedrails were used to meet resident needs and the risks associated
with bedrail usage for five of five residents (Residents R17, R21, R27, R29, and R30).
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 211.12 (d) (1)(3)(5) Nursing services.
28 Pa. Code 211.10(c)(d) Resident care policies.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 19 of 33
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
11/27/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on review of facility policies, observations, and staff interviews it was determined that the facility
failed to properly store medical supplies and biologicals in one of two medication rooms.
Findings include:
Review of the facility policy Medication Storage in the Facility dated 11/6/23, last reviewed on 11/4/24,
indicated all medications are maintained within the temperature ranges noted in the United States
Pharmacopeia (USP and by the Centers for Disease Control (CDC). Refrigerated 36 degrees Fahrenheit to
46 degrees Fahrenheit with a thermometer to allow temperature monitoring.
During an observation on 11/26/24, at 9:00 a.m. the first-floor medication room refrigerator temperature log
was not completed the following dates:
11/11/24.
11/19/24.
11/21/24.
During an interview on 11/26/24, at 9:07 a.m. Registered Nurse (RN) Employee E6 confirmed the above
observations and that the facility failed to properly store medical supplies and biologicals in one of two
medication rooms.
28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 20 of 33
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
11/27/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on a review of facility policies, observations, and staff interviews, it was determined that the facility
failed to properly date food items to ensure proper rotation, and failed to prevent possible
cross-contamination while storing food service items, and failed to properly perform handwashing in the
Main Kitchen.
Findings include:
A review of the facility policy Food Safety dated 11/4/24, and previously dated 11/6/23, indicated that the
facility will provide safe and sanitary storage, handling, and consumption of all food that includes storage,
preparations, distribution, and serving food in accordance with professional standards for food service
safety.
A review of the facility document Kitchen Porter/Dishwasher/Helper Job Description indicated that the
employee must maintain high standards of sanitation, safety, proper storage and handling in accordance
with Health Department, State, and Federal Codes.
During an observation in the Dry Foods Storage Area of the Main Kitchen on 11/25/24, at 9:25 a.m. it was
noted that none of the food items were dated at the time of receiving.
During an observation in the Walk- In Refrigerator and Walk-in Freezer on 11/25/24, at 9:30 a.m. it was
noted that none of the food items were dated at the time of receiving.
During an interview on 11/25/24, at 9:30 a.m. Dietary Supervisor Employee E7 confirmed that the facility
failed to date food items when they were received to ensure proper food rotation.
During an observation on 11/26/24, at 1:20 p.m. in the Dish Room, six casserole dishes, 12 bowls, eight
serving platters, six saucepans, seven frying pans were being stored on shelves in the drying area and
were not inverted to prevent cross contamination and proper drying.
During an interview on 11/26/24, at 1:22 p.m. Dietary Supervisor Employee E7 confirmed that the facility
failed to properly store dishes.
During an observation in the Dish Room on 11/26/24, at 1:25 p.m. Kitchen [NAME] (KP) Employee E8 was
noted to be wearing gloves and loading dirty dishes into the dish machine. The area of the Dish Room that
KP Employee E8 was working is where dirty dishes are loaded into the dish machine. This area has a sink
with a water sprayer to remove debris from the dishware prior to being loaded into the dish machine. No
hand soap is in this area, but there is a handwashing sink at the opposite end of the Dish Room. When the
clean dishes emerged from the other side of the dish machine, KP Employee E8 ran has gloved hands
under water for about two seconds before he went to retrieve the clean dishes.
During an interview on 11/26/24, at 1:25 p.m. KP Employee E8 was stopped by State Agency and was
advised that he did not remove his dirty gloves and wash his hands with soap and water prior to touching
clean dishes, to which KP Employee E8 confirmed that he failed to properly wash his hands.
During an interview on 11/26/24, at 1:25 p.m. Dietary Supervisor Employee E7 confirmed that the facility
failed to properly perform handwashing which created the potential for foodborne illness.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 21 of 33
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
11/27/2024
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 0812
28 Pa. Code: 211.6(c) Dietary services
Level of Harm - Minimal harm
or potential for actual harm
28 Pa Code 201.14 (a) Responsibility of licensee.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 22 of 33
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
11/27/2024
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
review of facility policy, observations, and staff interviews, it was determined that the facility failed to
properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for
two of two residents (Residents R17 and R29), failed to implement Enhanced Barrier Precautions (EBP) for
two of two residents (Residents R1 and R3), failed to provide a safe and sanitary environment to help
prevent the potential for cross contamination for one of two medication rooms (First Floor Medication
Room), and failed to implement infection control practices to prevent cross contamination during a dressing
change for one of three residents (Resident R29).
Residents Affected - Some
Findings include:
Review of facility policy Food Safety dated 11/6/23, last reviewed 11/4/24, indicated staff will be appointed
to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items
per facility policy.
The Centers for Disease Control defines Enhanced Barrier Precautions as: an infection control intervention
designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve
gown and gloves during high-contact resident care activities for residents known to be colonized or infected
with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or
indwelling medical devices).
Review of the facility policy Medication Storage in the Facility dated 11/6/23, last reviewed on 11/4/24,
indicated medications are stored safe, securely and properly. Medication storage areas are to be kept
clean, well lit, and free of clutter.
Review of the facility policy Dressing, Non-Sterile dated 11/6/23, last reviewed on 11/4/24, indicated to
protect, to absorb drainage and to promote healing of wound. Procedures includes but not inclusive to:
·
Obtain necessary supplies.
·
Wash hands and apply gloves.
·
Remove soiled dressing and place in trash bag.
·
Wash hands and apply new gloves Cleanse wound and surrounding tissue with normal saline solution and
dry gauze.
·
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 23 of 33
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
11/27/2024
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
Apply prescribed wound-care product.
Level of Harm - Minimal harm
or potential for actual harm
·
Discard gloves and all used supplies.
Residents Affected - Some
During an observation on 11/25/24, at 9:15 a.m. Resident R17 had a small personal refrigerator in her
room. There was a thermometer inside of the refrigerator, however there was no temperature log present.
During an interview on 11/27/24, at 9:16 a.m. the Director of Nursing (DON) stated that the household
aides are responsible for resident refrigerators.
During a review of Resident R17's Resident's Fridge Temperature Logs dated October 2024 and November
2024, revealed the following dates did not have a documented temperature: 10/1/24, 10/2/24, 10/3/24,
10/4/24, 10/9/24, 10/17/24, 10/18/24, 10/23/24, 10/24/24, 11/1/24, 11/4/24, and 11/16/24.
During an observation on 11/25/24, at 9:19 a.m. Resident R29 had a small personal refrigerator in her
room. There was a thermometer inside of the refrigerator, however there was no temperature log present.
During an interview on 11/25/24, at 9:24 a.m. Registered Nurse (RN) Employee E5 confirmed a
temperature log was not present.
During a review of Resident R29's Resident's Fridge Temperature Logs dated November 2024, indicated in
November only two days were logged: November 25, 2024, and November 26, 2024. No other logs were
provided for the previous months.
During an interview on 11/27/24, at 9:43 a.m. the Assistant Director of Nursing (ADON) Employee E2
confirmed that the facility failed to properly monitor personal refrigerators to ensure that food is properly
stored and maintained for two of two residents (Residents R17 and R29).
Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/27/24,
indicated diagnoses of coronary artery disease (CAD- arteries can't deliver enough oxygen to the heart),
Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements) and dysphagia
(difficult swallowing) Section K - Swallowing - Nutritional Status, indicated Resident R1 has a feeding tube.
Review of a physician order dated 12/23/23, indicated Two Cal HN (feeding formula) 240 ml (milliliter) at 80
ml every hour for 3 hours daily with water infusion of 50 ml every hour while formula is being administered.
Review of Resident R1's clinical record on 11/26/24, failed to reveal an order or care plan for Enhanced
Barrier Precautions in relation to Resident R1's tube feeding usage and care.
Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 24 of 33
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
11/27/2024
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
Review of Resident R3's MDS dated [DATE], indicated diagnoses of high blood pressure, weakness, and
need for assistance with personal care. Section H - Bladder and Bowel, indicated Resident R1 had an
indwelling catheter.
Review of a physician order dated 7/5/24, indicated Resident R3 had a suprapubic catheter.
Residents Affected - Some
Review of Resident R3's clinical record on 11/26/24, failed to reveal an order or care plan for Enhanced
Barrier Precautions in relation to Resident R3's suprapubic catheter usage and care.
During an interview on 11/26/24, at 1:19 p.m. the DON confirmed that the facility failed to implement
Enhanced Barrier Precautions for two of two residents (Residents R1 and R3).
During an observation on 11/26/24, at 9:00 a.m. of the First Floor Medication Room the following was
observed on the counter:
· One blue lunch bag.
· One bottle of water
The lower cupboard contained a smaller coach purse.
During an interview completed on 11/26/24, at 9:04 a.m. RN Employee E6 Stated, these are mine.
The medication room freezer contained three blue ice packs and ice buildup.
During an interview on 11/26/24, at 9:07 a.m. RN Employee E6 confirmed the above observations and that
the facility failed to provide a safe and sanitary environment to help prevent the potential for cross
contamination for one of two medication rooms.
Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE].
Review of Resident R29's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure),
diabetes (high sugar in the blood) and anemia (low iron in the blood).
Review of Resident R29's physician order dated 11/22/24, indicated to apply Medihoney gel to right buttock
and cover with foam bordered dressing every day shift.
Review of Resident R29's care plan dated 4/17/24, indicated staff will follow wound protocol as ordered.
Review of Resident R29's care plan dated 11/22/24, indicated staff to apply Medihoney gel and foam
bordered dressing to right buttocks daily.
During a wound care observation on 11/26/24, at 10:32 a.m. RN Employee E6 washed her hands, entered
Resident R29's room and assisted her to the bathroom with wheelchair, used hand sanitizer, gathered
supplies from Resident R29's bathroom closet and prepared dressing supplies on Resident R29's dresser.
RN Employee E6 took the supplies and placed on top of a plastic storage cart next to commode, no barrier
field was placed, applied gloves. She assisted Resident R29 to stand and removed pants and underwear,
cleansed, and dried the area, removed gloves, did not complete hand hygiene and continued
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 25 of 33
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
11/27/2024
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
Residents Affected - Some
to apply skin prep barrier to surrounding area followed with the Medi-honey and covered with dressing. She
then helped dress the resident and assisted to wheelchair. Picked up all discarded items and placed into
garbage can removed bag, washed hands picked up garbage and disposed of it in receptacle. Applied hand
sanitizer.
During an interview completed on 11/26/24, at 10:45 a.m. RN Employee E6 confirmed she failed to
implement infection control practices to prevent cross contamination during a dressing change for Resident
R29 by not initiating a clean barrier field prior to placement of dressing supplies. Not completing hand
hygiene after cleansing and patting the wound dry. Completing the wound care without the use of gloves
and not cleaning the storage cart surface after dressing was completed.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 26 of 33
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
11/27/2024
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 0941
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop, implement, and/or maintain an effective training program that includes effective communications
for direct care staff members.
Based on review of facility policy, facility documents and staff interviews, it was determined that the facility
failed to provide Communication training to four of seven direct care facility staff reviewed (Employees E1,
E10, E12 and E14).
Finding include:
Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated
11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain
written policies and procedures for verification of appropriate educational preparation and competency, to
include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed.
Proficiency in skills and techniques necessary to care for residents' needs includes competencies in areas
such as communication and personal skills, personal care skills, mental health and social service needs,
basic restorative services and resident rights.
During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that
education is conducted by calendar year running January through December.
Review of facility education documents for the year 2023 revealed the following concerns:
Review of Registered Nurse (RN) Employee E1's facility provided information did not include training on
effective communication.
Review of Nurse Aide (NA) Employee E10's facility provided information did not include training on effective
communication.
Review of NA Employee E12's facility provided information did not include training on effective
communication.
Review of RN Employee E14's facility provided information did not include training on effective
communication.
During an interview on 11/27/24, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to
provide Communication training to direct care facility staff.
28 Pa. Code: 201.14(a) Responsibility of Licensee
28 Pa. Code: 201.20(c) Staff Development
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 27 of 33
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
11/27/2024
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 0943
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to
report abuse, neglect, and exploitation.
Based on review of facility policy, facility documents, and staff interview, it was determined that the facility
failed to provide training on resident protection from abuse and neglect for two of seven staff members
(Employees E11, and E13).
Findings include:
Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated
11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain
written policies and procedures for verification of appropriate educational preparation and competency, to
include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed.
Review of the facility policy Abuse dated 11/4/24, and previously dated 11/6/23, indicated that all staff shall
be trained during orientation and on an on-going basis on issues related to reporting of resident abuse,
neglect or mistreatment.
During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that
education is conducted by calendar year running January through December.
Review of facility education documents for the year 2023 revealed the following concerns:
Review of Nurse Aide (NA) Employee E11's facility provided information did not include training on resident
protection from abuse and neglect.
Review of NA Employee E13's facility provided information did not include training on resident protection
from abuse and neglect.
During an interview on 11/27/24, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to
provide training on resident protection from abuse and neglect for two of seven staff members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 28 of 33
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
11/27/2024
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 0944
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement
Program.
Based on review of facility policy, facility documents, and staff interview, it was determined that the facility
failed to provide training on Quality Assurance and Performance Improvement (QAPI) for seven of seven
staff members (Employee E1, E9, E10, E11, E12, E13, and E14).
Findings include:
Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated
11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain
written policies and procedures for verification of appropriate educational preparation and competency, to
include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed.
During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that
education is conducted by calendar year running January through December.
Review of facility education documents for the year 2023 revealed the following concerns:
Review of Registered Nurse (RN) Employee E1's facility provided information did not include training on
QAPI education.
Review of Nurse Aide (NA) Employee E9's facility provided information did not include training on QAPI
education.
Review of NA Employee E10's facility provided information did not include training on QAPI education.
Review of NA Employee E11's facility provided information did not include training on QAPI education.
Review of NA Employee E12's facility provided information did not include training on QAPI education.
Review of NA Employee E13's facility provided information did not include training on QAPI education.
Review of RN Employee E14's facility provided information did not include training on QAPI education.
During an interview on 11/27/24, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to
provide training on QAPI for seven of seven staff members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 29 of 33
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
11/27/2024
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 0945
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Include as part of its infection prevention and control program, mandatory training that includes written
standards, policies, and procedures for the program.
Based on review of facility policy, facility documents, and staff interview, it was determined that the facility
failed to provide training on Infection Control for five of seven staff members (Employees E1, E9, E10, E12,
and E14).
Findings include:
Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated
11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain
written policies and procedures for verification of appropriate educational preparation and competency, to
include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed.
Review of the facility policy Infection Control dated 11/4/24, and previously dated 11/6/23, indicated that
initial orientation for new employees covers infection control, universal precautions, and hand washing. This
information is reviewed yearly.
During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that
education is conducted by calendar year running January through December.
Review of facility education documents for the year 2023 revealed the following concerns:
Review of Registered Nurse (RN) Employee E1's facility provided information did not include training on
Infection Control education.
Review of Nurse Aide (NA) Employee E9's facility provided information did not include training on Infection
Control education.
Review of NA Employee E10's facility provided information did not include training on Infection Control
education.
Review of NA Employee E12's facility provided information did not include training on Infection Control
education.
Review of RN Employee E14's facility provided information did not include training on Infection Control
education.
During an interview on 11/27/24, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to
provide training on Infection Control for five of seven staff members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 30 of 33
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
11/27/2024
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 0946
Provide training in compliance and ethics.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, facility documents, and staff interview, it was determined that the facility
failed to provide training on Compliance and Ethics for two of seven staff members (Employees E11, and
E13).
Residents Affected - Some
Findings include:
Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated
11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain
written policies and procedures for verification of appropriate educational preparation and competency, to
include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed.
During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that
education is conducted by calendar year running January through December.
Review of facility education documents for the year 2023 revealed the following concerns:
Review of Nurse Aide (NA) Employee E11's facility provided information did not include training on
Compliance and Ethics education.
Review of NA Employee E13's facility provided information did not include training on Compliance and
Ethics education.
During an interview on 11/27/24, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to
provide training on Compliance and Ethics for two of seven staff members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 31 of 33
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
11/27/2024
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 0947
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in
dementia care and abuse prevention.
Based on review of facility documents, and staff interviews it was determined that the facility failed to
ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each
year for five out of five Nurse Aide Employees (Employee E9, E10, E11, E12, and E13)
Findings include:
Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated
11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain
written policies and procedures for verification of appropriate educational preparation and competency, to
include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed.
During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that
education is conducted by calendar year running January through December.
Review of facility education documents for the year 2023 revealed the following concerns:
Review of Nurse Aide (NA) Employee E9's facility provided information indicated that she had received 7.75
hours of in-services and did not meet the required 12 hours of in-servicing.
Review of NA Employee E10's facility provided information indicated that she had received 2.5 hours of
in-services and did not meet the required 12 hours of in-servicing.
Review of NA Employee E11's facility provided information indicated that she had received 5.75 hours of
in-services and did not meet the required 12 hours of in-servicing.
Review of NA Employee E12's facility provided information indicated that she had received 4.0 hours of
in-services and did not meet the required 12 hours of in-servicing.
Review of NA Employee E13's facility provided information indicated that she had received 7.75 hours of
in-services and did not meet the required 12 hours of in-servicing.
During an interview on 11/27/24, at 10:35 a.m. the Director of Nursing confirmed that the facility failed to
provide the required 12 hours of annual in-service education for five out of five Nurse Aide Employees.
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 32 of 33
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
11/27/2024
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 0949
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide behavior health training consistent with the requirements and as determined by a facility
assessment.
Based on review of facility policy, facility documents and staff interviews, it was determined that the facility
failed to provide training on Behavioral Health for three of seven staff members (Employees E1, E10, and
E14).
Findings include:
Review of the facility policy Nursing Education, Mandatory Training and Competency Evaluation dated
11/4/24, and previously dated 11/6/23, indicated that the facility will establish, implement and maintain
written policies and procedures for verification of appropriate educational preparation and competency, to
include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed.
During an interview on 11/26/24, at 1:45 p.m. Human Resources Director Employee E15 stated that
education is conducted by calendar year running January through December.
Review of facility education documents for the year 2023 revealed the following concerns:
Review of Registered Nurse (RN) Employee E1's facility provided information did not include training on
Behavioral Health education.
Review of Nurse Aide (NA) Employee E10's facility provided information did not include training on
Behavioral Health education.
Review of RN Employee E14's facility provided information did not include training on Behavioral Health
education.
During an interview on 11/27/24, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to
provide training on Behavioral Health for three of seven staff members.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396116
If continuation sheet
Page 33 of 33
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
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.
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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.
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.
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.
- 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: "Allow residents to easily view the nursing home's survey results and communicate with advocate agencies."
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.