Pennsylvania Department of Health
LITTLE SISTERS OF THE POOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LITTLE SISTERS OF THE POOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to an incident, completed on October 28, 2025, it was determined that Little Sister of The Poor was not in compliance with the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision during bathing for one of three residents (Resident R1). This failure was determined to be past non-compliance.

Findings include:

Review of the facility policy "Bath, Mechanical Lift" dated November 2024, indicated before helping resident into or out of chair, lock the wheels of the carrier. Lock the carrier onto patient transfer lift. Be sure belts are tight on chair. Before moving resident, fasten seat belt onto resident.

Review of the facility's "Resident Bathing Safety: Quick Reference Guide" dated November 2024, indicated review care plan for bathing assistance level. Stay with resident at all times. If you must step away: call another aide or nurse to stay with the resident. Never rely on "just telling them to wait". Use proper lifting/transfer equipment as needed. Use all available safety mechanisms, i.e. bars, seatbelts, etc. Unsupervised bathing is a serious violation of resident rights, facility policy and federal regulations.

Review of the Admission Record indicated Resident R1 was admitted to the facility on 11/23/20.

Review of R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/13/25, indicated the diagnoses of high blood pressure, arthritis (inflammation and pain in the joints), and Schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behaviors, and decreased participation in activities of daily living). Section C0500 - Brief Interview for Mental Status (BIMS -is a screening test that aids in detecting cognitive impairment) indicated a score of thirteen - cognitively intact.

Review of Resident R1's current care plan, indicated resident needs assistance with activities of daily living (ADL's). Staff will assist her into the tub twice weekly.

Review of Resident R1's progress note dated 9/29/25, at 7:50 a.m. indicated staff was informed that Resident R1 was in the bathing room yelling for help. At the time staff heard yelling, they ran into bathing room and found resident sliding down in the bath chair. They immediately pulled resident up in the chair and secured the safety belt.

Review of facility provided documentation dated 9/29/25, at 7:35 a.m. indicated the household supervisor arrived on unit and heard screaming coming from the bathing room. Resident R1 was in bath chair sliding down and water was up to the collarbone/neck and resident was yelling, "Help me, help me." Bath chair belt was not strapped, handlebar was not in front of resident, and the bath chair wheels were unlocked. When asked who put resident in the tub, resident responded "The agency girl." The supervisor and another Nurse Aide (NA) drained some water and used a towel to sit resident up and strapped resident into bath chair. Once secure, the bath was completed and hair washed. Resident denied going under the water. No noted injuries. Assessment of resident: respirations easy and unlabored, lungs clear throughout, vital signs stable, and afebrile.

Interview on 10/28/25, at 9:35 a.m. Resident R1 indicated recalling the episode in the bathtub. Resident indicated feeling temporarily terrified at the time of being left alone in the tub. Resident believes it was overall about ten minutes because the agency NA left immediately after placing resident in the tub. Resident stated the NA was asking the resident how the machine works, because the facility had not taught NA how to use it. Resident indicated they were not afraid of bathing and felt safe as long as the regular staff took care of resident.

Interview with the Director of Nursing on 10/28/25, at 11:00 a.m. confirmed the facility failed to provide adequate supervision during bathing for one of three residents (Resident R1) and requested past non-compliance status be reviewed for the event and handed over information on immediate interventions and education that had been completed on bathing and supervision by the facility.

Review of the facility's corrective actions on 10/28/25, at 2:45 p.m. verified the following had been met by the facility:
-Resident R1 was immediately assisted in tub, assessed by nursing and physician with no injuries and only temporarily terrified during the time left alone in the tub.
-NA Employee E1 was interviewed and immediately sent home from the facility.
-Resident R1's care plan was updated on 9/29/25, indicated resident has had a bad experience while being bathed in the whirlpool. Resident will express satisfaction and comfort with their bathing routine. Resident will only be assisted with bathing by trained staff and will not be left alone during bathing. Social services to visit and monitor mood and behaviors and offer counseling to express any feelings about the incident. Staff will encourage resident to express concerns regarding bathing.
-Review of Resident R1's progress notes revealed seventeen daily visits from social services from 9/29/25, through 10/27/25. Resident expressed no ill effects from the incident.
-All nursing staff 66 of 66 facility nursing staff and 11 of 15 agency nurse aides were re-educated on resident bathing safety and equipment, and ensuring a resident in a tub is never left unattended.
-In person interviews on 10/28/25, indicated six of six NAs on site received training and understood the education.
-Any new facility nursing staff or newly assigned agency staff will receive resident bathing safety and equipment, and ensuring a resident in a tub is never left unattended prior to the start of their shift.
-Observation on 10/28/25, of all four whirlpool rooms in the facility indicated appropriate equipment available and signage with safety reminders in all areas for staff reference.
-As of 10/6/25, over 95% of nursing staff received training and education, and the facility was determined to be past non-compliance as of 10/6/25.

Exit interview on 10/28/25, at 2:45 p.m. information was provided to the Nursing Home Administrator and the Director of Nursing that the facility failed to make certain each resident received adequate supervision during bathing for one of three residents (Resident R1) and that the facility had successfully met the task of Past Non-Compliance effective 10/6/25, when the corrective actions were achieved by the facility.

28 Pa. Code 201.14 Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 201.29 Responsibility of Licensee.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
28 Pa. Code 211.10(d) Resident care policies.

Plan of Correction - To be completed: 11/07/2025

Past noncompliance: no plan of correction required.

483.95(a) REQUIREMENT Communication Training:

§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.

Observations:

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for nine of ten staff members (Nurse Aides (NA) Employee E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E9, Licensed Practical Nurse (LPN) Employee E10, and Registered Nurse (RN) Employee E11).

Findings include:

Review of facility provided documents and training records for NA E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E9, LPN Employee E10, and RN Employee E11 failed to include education on effective communication as required.

Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training on effective communication for nine of ten staff members (NA E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E9, LPN Employee E10, and RN Employee E11).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(6)(d) Staff development.

Plan of Correction - To be completed: 11/26/2025

0941- Communication Training
- NA E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E9, LPN Employee E10, and RN Employee E11will be re-educated on the required effective communication.
- All nursing staff will be re-educated by the Director of Nursing (DON) or designee on Effective Communication.
- The required communication training will be added to the new hire and annual training plan.
- The Nursing Home Administrator (NHA), or designee will audit all new hires for the required Communication training. Audits will be conducted monthly X3 and quarterly X1.
- All audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations.

483.95(b) REQUIREMENT Resident Rights Training:

§483.95(b) Resident's rights and facility responsibilities.
A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents as set forth at §483.10, respectively.

Observations:

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for one of ten staff members (Nurse Aide (NA) Employee E4).

Findings include:

Review of facility provided documents and training records for NA Employee E4 failed to include education on
Resident Rights as required.

Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training on Resident Rights for one of ten staff members (NA Employee E4).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(6)(d) Staff development.

Plan of Correction - To be completed: 11/26/2025

0942-Resident Rights Training
- Employee E12 (Agency Aide) will be re-educated on the required Resident Rights Training.
- The Nursing Home Administrator (NHA), or designee will provide education to all Agency vendors on Skilled facility educational requirements per the State and Federal regulations.
- The resident rights education will be added to the Agency orientation Binder.
- The facility will conduct a full house audit of current employees and active agency members to ensure all employees have received the required Resident Rights Training. The Director of Nursing (DON) or designee will provide Re-education to any employee identified as not receiving the required training in the last 12 months.
- The Nursing Home Administrator (NHA), or designee will audit all new hires, and new Agency employee training records for the required Resident Rights training. Audits will be conducted monthly X3 and quarterly X1.
- All audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations.

483.95(d) REQUIREMENT QAPI Training:

§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.

Observations:

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for three of ten staff members (Nurse Aides (NA) Employees E2, NA E3, and NA E4).

Findings include:

Review of facility provided documents and training records for NA Employees E2, NA E3,and NA E4, failed to include education on QAPI as required.

Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training for QAPI for three of ten staff members (NA Employees E2, NA E3, and NA E4).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(6)(d) Staff development.

Plan of Correction - To be completed: 11/26/2025

0944- QAPI Training
- Employees E2, NA E3, and NA E4 (Agency Aides) will be re-educated on the required Quality Assurance Performance Improvement (QAPI) Training.
- The Nursing Home Administrator (NHA), or designee will provide education to all Agency vendors on Skilled facility educational requirements per the State and Federal regulations.
- The Quality Assurance Performance Improvement (QAPI) education will be added to the Agency orientation Binder.
- The facility will conduct a full house audit of current employees and active agency members to ensure all employees have received the required Quality Assurance Performance Improvement (QAPI) Training. The Director of Nursing (DON) or designee will provide Re-education to any employee identified as not receiving the required training in the last 12 months.
- The Nursing Home Administrator (NHA), or designee will audit all new hires, and new Agency employee training records for the required Quality Assurance Performance Improvement (QAPI) training. Audits will be conducted monthly X3 and quarterly X1.
- All audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations.

483.95(f)(1)(2) REQUIREMENT Compliance and Ethics Training:

§483.95(f) Compliance and ethics.
The operating organization for each facility must include as part of its compliance and ethics program, as set forth at §483.85-

§483.95(f)(1) An effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program.

§483.95(f)(2) Annual training if the operating organization operates five or more facilities.

Observations:

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide Compliance and Ethics training for three of ten staff members (Nurse Aides (NA) Employees E2, NA E3, and NA E4).

Findings include:

Review of facility provided documents and training records for NA Employees E2, NA E3, and NA E4, failed to include education on Compliance and Ethics as required.

Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training for Compliance and Ethics for three of ten staff members (NA Employees E2, NA E3, and NA E4).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(6)(d) Staff development.

Plan of Correction - To be completed: 11/26/2025

0946- Compliance and Ethics
- Employees E2, NA E3, and NA E4 (Agency Aides) will be re-educated on the required Compliance and Ethics Training.
- The Nursing Home Administrator (NHA), or designee will provide education to all Agency vendors on Skilled facility educational requirements per the State and Federal regulations.
- Compliance and Ethics education will be added to the Agency orientation Binder.
- The facility will conduct a full house audit of current employees and active agency members to ensure all employees have received the required Compliance and Ethics Training. The Director of Nursing (DON) or designee will provide Re-education to any employee identified as not receiving the required training in the last 12 months.
- The Nursing Home Administrator (NHA), or designee will audit all new hires, and new Agency employee training records for the required Compliance and Ethics training. Audits will be conducted monthly X3 and quarterly X1.
- All audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations.

483.95(i) REQUIREMENT Behavioral Health Training:

§483.95(i) Behavioral health.
A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71.

Observations:

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide Behavioral training for three of ten staff members (Nurse Aides (NA) Employee E6, NA E8, and Licensed Practical Nurse (LPN) Employee E10.

Findings include:

Review of facility provided documents and training records for NA Employee E6, NA E8, and LPN Employee E10 failed to include Behavioral training as required.

Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide Behavioral training for three of ten staff members (Nurse Aides (NA) Employee E6, NA E8, and Licensed Practical Nurse (LPN) Employee E10.

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(6)(d) Staff development.

Plan of Correction - To be completed: 11/26/2025

0949 Behavioral Health Training
- Nurse Aides (NA) Employee E6, NA E8, and Licensed Practical Nurse (LPN) Employee E10 will be re-educated on the required Behavioral Health Training.
- All nursing staff will be re-educated by the Director of Nursing (DON) or designee on Behavioral Health.
- The required Behavioral Health training will be added to the new hire and annual training plan.
- The Nursing Home Administrator (NHA), or designee will audit the training records of all new hires and new agency employees for the required Behavioral Health training. Audits will be conducted monthly X3 and quarterly X1.
- All audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations.

§ 201.20(a)(2) LICENSURE Staff development.:

(2) Restorative nursing techniques.

Observations:

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on Restorative Nursing for ten of ten staff members (Nurse Aides (NA) Employee E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E8, NA E9, Licensed Practical Nurse (LPN) Employee E10, and Registered Nurse (RN) Employee E11).

Findings include:

Review of facility provided documents and training records for NA E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E8, NA E9, LPN Employee E10, and RN Employee E11 failed to include education on Restorative Nursing as required.

Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training on Restorative Nursing for ten of ten staff members (NA E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E8, NA E9, LPN Employee E10, and RN Employee E11).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(6)(d) Staff development.

Plan of Correction - To be completed: 11/26/2025

1560 Restorative Nursing Techniques
- Nurse Aides (NA) Employee E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E8, NA E9, Licensed Practical Nurse (LPN) Employee E10, and Registered Nurse (RN) Employee E11 will be re-educated on the required Restorative Nursing Techniques Training.
- All nursing staff will be re-educated by the Director of Nursing (DON) or designee on Restorative Nursing Techniques.
- The required Restorative Nursing Techniques training will be added to the new hire and annual training plan.
- The Nursing Home Administrator (NHA), or designee will audit the training records of all new hires and new agency employees for the required Restorative Nursing Techniques training. Audits will be conducted monthly X3 and quarterly X1.
- All audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations.

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