Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Little Falls Care Center during CMS and state inspections, most recent first.
A facility failed to consistently obtain and administer ordered meds for three residents. One resident on scheduled hydromorphone and pregabalin missed multiple doses and reported withdrawal symptoms, while another resident missed numerous Duoneb treatments and a third missed oxycodone doses because staff documented no supply and pharmacy forms indicated new scripts or signed orders were needed. The DON and NP confirmed the missed doses and that staff did not adequately follow up or report the resident’s symptoms.
The facility failed to consistently include the daily census on nurse staff postings and had PBJ staffing data that triggered survey review for low weekend staffing and LNs available 24 hours per day. Although posted schedules showed licensed nursing coverage 24/7, the staffing coordinator said they only entered agency staff, and the administrator stated corporate submitted PBJ, contract/agency staff may not have been entered, and nurse manager hours may have been coded incorrectly when worked on the floor.
A laundry aide stated soiled linens were sorted by item type and unit and that only gloves were worn during sorting, while gowns in the room were said to be for COVID only. The ES director stated staff were expected to wear gloves and gowns when sorting soiled linens, and the facility's Linen Handling policy required appropriate PPE and standard precautions for all soiled linens.
A facility failed to notify the provider about missed meds for three residents and a change in condition for one resident. One resident with COPD missed 34 Duoneb treatments, another resident missed 12 hydromorphone doses and 10 pregabalin doses and later showed withdrawal symptoms, and a third resident missed 9 oxycodone doses because meds were out of supply. The record lacked evidence the provider was notified of the missed doses, and the resident with withdrawal symptoms also lacked timely provider notification of the change in condition.
Meal trays were not delivered to residents in a timely manner to maintain safe and appetizing temperatures. Surveyors observed trays sitting on a pod for about 20 minutes, uncovered and waiting for delivery, and found multiple foods on sampled trays below expected temperatures. A CNA reheated one tray in a microwave but did not check the temp, and the DON/Administrator were unsure whether floor staff had been trained on required food temps before serving.
Inaccurate Nutritional Care Plan: A resident with HF, COPD, and dysphagia had significant weight loss and was on a soft and bite sized diet with mildly thickened liquids, but the care plan was not updated to reflect current nutritional status. The plan listed a goal weight range that did not match the resident’s documented weight goals, and the DON confirmed the care plan lacked accurate current information.
Failure to Address Significant Weight Loss: A resident with COPD, HF, dysphagia, and parkinsonism experienced significant unintentional weight loss while on a modified diet and weekly weight monitoring. The nutritional assessment did not identify dysphagia or nutritional needs, the care plan lacked a dietary supplement intervention, and staff interviews confirmed the resident continued to lose weight despite fortified foods. The DON acknowledged the loss was significant, and the RD stated the resident should also have been receiving a supplement such as Ensure or Boost.
Outdated Resident Bill of Rights Posted: An outdated RBOR was observed posted in the facility, and the SSD confirmed the information was outdated. The SSD stated it was their responsibility to keep the posting updated, but it had not been completed. A policy regarding posting the RBOR was requested and none was provided.
A resident with dementia, bowel incontinence, and a PEG tube developed a clear change in stool consistency, but the bowel assessment was left incomplete and the change was not evaluated before the resident later had vomiting, abdominal distention, and a hospital transfer for possible bowel obstruction. In a separate issue, the facility did not communicate ordered lab testing and abnormal results for another hospice resident to the hospice team, and hospice staff said they were unaware the tests had been done.
Failure to assess and monitor new skin tears and bruising: two residents with significant cognitive and medical impairments had new skin findings that were not fully documented or followed in the medical record. One resident had a right wrist skin tear with a dressing in place but no documentation of the injury, while another resident had a bruise on the lower back with no further assessment or monitoring recorded. Staff stated they were expected to document the findings, notify the provider, and add monitoring orders, but those steps were not completed.
A resident with severe cognitive impairment, vascular neurocognitive disorder, gait abnormalities, repeated falls, and hemiparesis experienced multiple unwitnessed falls over several weeks. Although the care plan addressed extensive ADL assistance, toileting, repositioning, and behavioral analysis, it did not incorporate a psychiatric recommendation for 24-hour supervision. Documentation showed inconsistent or absent root cause analyses after several falls, and the care plan was not revised to reflect the resident’s ongoing fall pattern or the psychiatric evaluation. Staff interviews revealed that NAs and nurses were unaware of new interventions, had not received education on managing the resident’s repeated falls, and did not know about the psychiatric recommendation, while the DON confirmed that supervision levels and the care plan had not been updated despite the facility’s fall prevention policy requiring comprehensive analysis after multiple falls. A family member reported inconsistent toileting, lack of notification about falls, and finding the resident incontinent and unattended.
A resident with significant mobility and cognitive impairments was transferred for a weight check without required footwear or a gait belt, and was left unsupported by staff. The resident lost balance while stepping off the scale, fell, and sustained a head injury resulting in a brain bleed. Staff and family interviews confirmed that the care plan was not followed during the transfer, leading to the incident.
A resident with severe cognitive impairment sustained a skin tear that was treated by nursing staff, but the physician was not notified until two days later and the resident's representative was not promptly informed. Staff interviews and documentation confirmed that required notifications were delayed, contrary to facility expectations for immediate reporting of new injuries.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive the necessary behavioral health care and services required, as observed and documented by surveyors.
A resident reported feeling uncomfortable and fearful during personal care by a nursing assistant, who allegedly continued despite her request to stop. The incident, involving the assistant's inappropriate behavior, was not reported to the State Agency until nearly two days later, violating the facility's guidelines for immediate reporting of abuse allegations.
A resident with type 2 diabetes and hypertension fell out of bed while trying to reach the fridge. Despite safety measures, the incident was not reported to the provider or resident representative due to a chaotic night shift. The facility's policy requires immediate notification, which was not followed, resulting in a deficiency.
A facility failed to follow physician orders for pressure ulcer care and infection control practices during a dressing change for a resident with multiple pressure ulcers. The RN did not perform hand hygiene between glove changes and omitted applying Santyl ointment as ordered. The resident had significant tissue damage, and the nurse practitioner highlighted the importance of following orders and maintaining hand hygiene for wound healing.
The facility failed to submit accurate direct care staffing information to CMS for Quarter 1. The PBJ report indicated excessively low weekend staffing, which was not supported by staffing schedules. The administrator stated that a data entry error at the corporate office affected all 15 facilities and was corrected before the next quarter's submission. No PBJ entry policy was available.
The facility failed to notify the families of two residents timely regarding significant changes in condition and their deaths. One resident's family was informed two hours after the resident passed away, and another resident's family was not notified about a fall, facial injuries, or hospitalization until much later. Staff interviews confirmed the lack of timely family notification, contrary to the facility's policy.
The facility failed to ensure three residents were comprehensively assessed for self-administration of medications. Despite assessments indicating they could not self-administer and did not wish to, residents were observed self-administering nebulizer treatments and an inhaler without proper oversight or documentation.
The facility failed to provide a written bed hold policy to a resident or their representative during a hospital transfer. The resident, who required assistance with ADLs, was hospitalized and returned without documented evidence of bed hold communication, contrary to the facility's policy.
The facility failed to follow provider orders for monitoring vital signs for a resident with serious diagnoses and did not obtain a necessary physician order for a lap positioning belt for another resident. Documentation and interviews confirmed these deficiencies.
The facility failed to assess past trauma and implement a trauma-informed care plan for a resident with PTSD, anxiety, and depression. Staff were unaware of the resident's trauma history, and the care plan lacked necessary interventions and trigger identification.
The facility failed to ensure the consulting pharmacist identified irregularities in monthly drug regimen reviews for three residents. The medical records lacked evidence of required orthostatic blood pressure monitoring and AIMS assessments, and the facility's psychotropic medication policy did not address these needs.
The facility failed to monitor orthostatic blood pressures and conduct AIMS assessments for residents on psychotropic medications, leading to a deficiency in ensuring the safety and well-being of these residents. Interviews revealed gaps in the monitoring process and inadequacies in the facility's psychotropic medication policy.
The facility failed to ensure that three residents were offered and/or provided the Influenza and pneumococcal vaccines as recommended by the CDC. Documentation of declination forms, education, and shared clinical decision-making with physicians was missing.
The facility failed to notify the LTC Ombudsman of hospitalizations for five residents, despite their medical records indicating various serious conditions requiring hospitalization. The Ombudsman had not received any notices of transfers or discharges for over a year, and the facility could not provide records or policies to show compliance with notification requirements.
The facility failed to review and revise its infection control policies annually, potentially affecting all residents, staff, and visitors. Key policies had not been updated for several years, and interviews revealed that the facility relied on corporate policies without conducting individual annual reviews.
The facility failed to ensure timely call light responses, leading to prolonged waiting times and incontinence for two residents. One resident waited up to 62 minutes for toileting assistance, while another waited up to 45 minutes, causing feelings of neglect and embarrassment. Staff interviews confirmed that the expected response time was 15 minutes, but this was not met, violating the facility's policies on call light response and resident dignity.
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in providing necessary assistance. One resident experienced multiple instances of waiting over 20 minutes, and in one case over an hour, for help with toileting, resulting in urine accidents and discomfort. Another resident also faced delays, leading to incontinence episodes and feelings of shame and embarrassment. Staff interviews confirmed that the expected response times were not being met due to insufficient personnel.
A resident who recently had hip surgery and required assistance with toileting was not checked or changed for almost seven hours due to staffing issues. The resident was found with a large amount of stool and urine in his brief, indicating that the scheduled toileting plan was not followed.
The facility failed to follow physician orders for a resident with moisture-associated skin damage (MASD), leading to the deterioration of the wound. Staff used inappropriate materials and techniques, such as peri wipes and packing the wound with fingers, instead of following the prescribed wound care procedures. The resident's wound showed signs of worsening, including increased tunneling and a strong foul odor.
The facility failed to implement recommended influenza A infection control procedures, specifically the use of masks, during direct care with two residents who tested positive. Staff members were observed entering and exiting the rooms without the necessary PPE, despite the residents' frequent coughing. Interviews revealed a lack of clarity and adherence to infection control policies.
The facility failed to notify a resident's representative and physician of multiple falls, both with and without injuries. The resident, diagnosed with dementia and anxiety disorder, experienced several falls over a period, with no documented notifications to the representative or physician. Interviews with staff confirmed that the expected notifications were not made, contrary to the facility's policy.
A resident with dementia and benign prostatic hyperplasia showed signs of a UTI, including hematuria and increased confusion. Despite these symptoms, the facility failed to implement the UTI protocol or notify the physician promptly. The resident's condition worsened, leading to hospitalization and death. Staff interviews confirmed awareness of symptoms but non-compliance with the facility's UTI protocol.
A facility failed to re-assess and revise the care plan for a cognitively impaired resident with multiple falls. Despite several falls and discussions by the interdisciplinary team (IDT), interventions were not consistently documented or implemented. Incident reports, root cause analyses, and care plan revisions were also lacking for several falls, and staff were not fully aware of all fall interventions.
The facility failed to identify target behaviors, revise care plans to include non-pharmacological interventions, and monitor effectiveness for three residents prescribed psychotropic medications. The Director of Nursing confirmed the lack of evidence in the medical records for target behaviors and monitoring, contrary to the facility's policy.
Medication supply and administration failures
Penalty
Summary
The facility failed to implement a system to ensure medications were consistently acquired, received, and administered as ordered for three residents. R20, who was cognitively intact and had diagnoses including COPD, type 2 diabetes with diabetic neuropathy, anxiety, and moderate protein-calorie malnutrition, was on scheduled hydromorphone 4 mg BID and pregabalin 100 mg TID for chronic pain. The record showed repeated missed doses because staff documented no supply of the medications, and the facility did not provide evidence of follow-up with the provider between the initial refill request and later requests when the resident was already out of medication. R20’s MAR showed 12 missed doses of hydromorphone and 10 missed doses of pregabalin. Progress notes documented that staff repeatedly noted no supply for the missed doses, and later notes described the resident as not feeling well, losing appetite, having SOB, and feeling like his skin was crawling. The resident stated he went without the medications for days and experienced shaking, SOB, sweating, nausea, heart racing, severe pain, and withdrawal symptoms. The on-call NP stated the nurse did not report the missed doses or the resident’s symptoms, and the DON confirmed the missed doses and that staff should have followed up with the provider and notified the provider of suspected withdrawal symptoms. R4, who was cognitively intact and had diagnoses including vascular parkinsonism, heart failure, and COPD, had an order for Duoneb nebulizer treatments TID. The July MAR showed 34 missed Duoneb treatments over multiple days, with progress notes repeatedly stating no supply. The pharmacy had requested an updated signed med list and later indicated a new signed order was needed. R22, who had moderate cognitive impairment and diagnoses including COPD, spondylosis, and chronic pain syndrome, had an order for oxycodone 5 mg BID. The July MAR showed 9 missed doses, and progress notes again documented no supply. Pharmacy forms indicated a new script was needed, and an LPN emailed the provider requesting a prescription for the oxycodone.
Incomplete PBJ Staffing Reporting and Daily Census Posting
Penalty
Summary
The facility failed to consistently include the facility census on the daily nurse staff posting. Survey review of the Payroll Based Journal (PBJ) staffing data showed the facility was triggered for review for low weekend staffing and for licensed nurses available 24 hours per day during the 1st quarter of 2026 on several weekend dates, and for licensed nurses available 24 hours per day during the 2nd quarter of 2026 on several weekend dates. The deficiency affected all 60 current residents, their families, and visitors. Review of the facility’s staff postings and actual working schedules for Quarter 1 and Quarter 2 showed licensed nursing staff were present 24 hours per day, 7 days per week, and the review did not identify weekends that were excessively low for staffing. During interview, the staffing coordinator stated they were only responsible for entering agency staff information and were not sure why the facility triggered on PBJ. The administrator stated corporate submitted the PBJ, was not sure whether contract or agency staff had been entered, and said PBJ submission was an area for improvement because it had not been submitted appropriately. The administrator also stated there was a high probability that nurse manager hours were not coded correctly when they worked the floor as floor nurses. A facility policy regarding PBJ reporting was requested but not provided.
Improper PPE Use When Sorting Soiled Linens
Penalty
Summary
The facility failed to implement proper infection control procedures when handling soiled linens. During observation and interview, a laundry aide stated that soiled laundry was sorted by item type and by unit and that gloves were the only personal protective equipment worn when sorting soiled linens. The aide also stated that the gowns hanging in the room were only for COVID. During interview, the environmental services director stated his expectation was that staff wore gloves and gowns when sorting soiled linens. Facility policy titled "Linen Handling," last updated 3/10/26, indicated staff must wear appropriate personal protective equipment based on anticipated exposure and in accordance with standard precautions and to handle all soiled linens as potentially infectious.
Failure to Notify Provider of Missed Medications and Change in Condition
Penalty
Summary
The facility failed to notify the provider of missed medications for three residents reviewed for medication errors. R4, who was cognitively intact and had diagnoses including vascular parkinsonism, heart failure, and COPD, had an order for Duoneb nebulizer treatments three times daily for COPD. The July MAR showed 34 missed Duoneb treatments from 7/9/26 through 7/20/26, and progress notes documented that staff noted no supply for each missed treatment. R4 also requested a PRN nebulizer treatment for shortness of breath on 7/16/26, but the record lacked evidence that the provider was notified of the missed treatments. R20, who was cognitively intact and had diagnoses including COPD, type 2 diabetes with diabetic neuropathy, anxiety, and moderate protein-calorie malnutrition, had long-term orders for hydromorphone 4 mg BID and pregabalin 100 mg TID for chronic pain. The July 2026 MAR showed 12 missed hydromorphone doses and 10 missed pregabalin doses because the medications were out of supply, and progress notes documented no supply for each missed dose. The record lacked evidence that the provider was notified of the missed doses. R20 later had documented complaints of not feeling well, loss of appetite, SOB, skin crawling, difficulty sleeping, and signs and symptoms of withdrawal, and the on-call NP stated the nurse had requested only refill orders and had not reported the missed doses or symptoms. R22, who had moderate cognitive impairment and diagnoses including COPD, spondylosis, and chronic pain syndrome, had an order for oxycodone 5 mg BID for chronic pain syndrome. The July MAR showed 9 missed oxycodone doses from 7/18/26 through 7/22/26 because there was no supply, and progress notes documented no supply for each missed dose. The record lacked evidence that the provider was notified of the missed oxycodone doses. The facility’s Change in Condition policy stated that the facility would inform the resident, consult with the physician, and notify the resident representative when a change occurred, and the DON stated nurses were expected to notify the provider in SBAR form for missed medications and changes in condition.
Meal trays not served at proper temperatures
Penalty
Summary
The facility failed to ensure meal trays were served in a timely manner to preserve desired temperatures and palatability for 6 of 6 resident trays sampled. During observation and interview, the Dietary Manager recorded temperatures on a resident tray that included chicken at 105 degrees, potato at 108 degrees, sliced carrots at 94 degrees, jello at 53 degrees, cranberry juice at 60 degrees, and ice water at 52 degrees. The Dietary Manager stated meals on the pod were dished in the dining room before residents were allowed in, and that staff on each pod were alerted by walkie talkie when trays were being delivered. The Dietary Manager stated dietary staff were responsible for delivering trays to one pod and floor staff on Maple were responsible for delivering those trays, but could not state how long trays sat on each pod before being delivered. During later observations, a large uncovered cart of meal trays was seen sitting in the pod waiting to be delivered, with plates covered on trays but not enclosed in a cart or on warmer plates. A nursing assistant confirmed the trays had been dropped off about 20 minutes earlier and stated she reheated one tray in the microwave but did not check the food temperature and was not aware she should. When the Dietary Manager returned with a thermometer, two resident trays were found to have food temperatures below expectations, including eggs at 87 degrees, toast at 82 degrees, bacon at 78 degrees, coffee at 114 degrees, milk at 58 degrees, pancakes at 92 degrees, sausage at 93 degrees, bacon at 86 degrees, and strawberries at 70 degrees. The Dietary Manager and Administrator stated they were unsure whether floor staff had been trained on the required food temperatures before serving, and no policy related to food temperatures was provided.
Inaccurate Nutritional Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with heart failure, COPD, and dysphagia to address nutritional status. The resident’s quarterly MDS showed the most recent admission was 4/10/26 and that the resident was cognitively intact. Record review showed the resident’s most current weight was 168.6 lbs and that the resident had a 14.33% weight loss over 6 months. A nutritional risk assessment completed 6/8/26 documented a weight of 173 lbs on 6/2/26, a goal weight of 172-185, oral intake of 51-75% of meals served, and a current ordered diet of soft and bite sized with mildly thickened liquids. The dietary assessment completed 6/8/26 stated the resident did not have a swallowing disorder and was not on a prescribed weight-loss regimen. The care plan reviewed 8/28/26 identified a focus of potential for altered nutrition and a goal of maintaining weight within 5% of admission weight, but it listed a goal weight range of 200-220 lbs, which did not match the resident’s current nutritional status or other record information. During interviews, the LPN manager stated he was familiar with the resident’s dysphagia and altered diet, and the DON stated care plans were completed primarily by unit managers and should be reviewed routinely for accuracy and updated to reflect current needs. The DON confirmed the resident’s care plan lacked accurate current information and had not been updated to reflect current nutritional status and weight goals.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor weights and failed to develop or modify specific interventions for a resident with significant, unintentional weight loss. The resident had diagnoses including COPD, heart failure, dysphagia, and parkinsonism, and the quarterly MDS identified cognitive intactness. The nutritional risk assessment documented a current weight of 173 lbs., a 4% loss over 30 days, a 10.3% loss over 180 days, and a goal weight of 172-185 lbs., but it did not recognize the resident’s dysphagia diagnosis or identify estimated nutritional needs. The dietary assessment noted the resident was not on a prescribed weight-loss regimen and was receiving a mechanically altered diet. The resident’s orders included weekly weights and a soft and bite size texture diet with nectar thick liquids, but there was no order for dietary supplements to address the weight loss. A progress note documented no decrease in food intake over the prior 3 months, weight loss greater than 3 kg in the previous 3 months, and a mini nutrition score of 11 indicating risk for malnutrition. The resident required assistance with meals due to occasional swallowing difficulty. The care plan addressed potential alteration in nutrition with goals of maintaining weight within 5% of admitted weight and adequate nutritional intake, with interventions including encouragement to feed self, fortified foods, weekly weights, and offering substitutes for dislikes, but it did not include a dietary supplement. Review of weights from 2/17/26 through 7/28/26 showed a 14.33% weight loss over 6 months, with weights declining from 192.6 lbs. to 165.0 lbs. Staff interviews confirmed the resident had dysphagia and steadily lost weight. The LPN stated the resident fluctuated between partial and full assistance with meals and that the facility RD was aware of the weight loss, though the LPN could not confirm whether the PCP was notified. The DON acknowledged the resident had lost greater than 14% over 6 months and agreed this was significant weight loss. The RD stated a fortified diet had been put in place but the resident should also have been receiving a dietary supplement such as Ensure or Boost, and could not identify why that recommendation had not been made.
Outdated Resident Bill of Rights Posted
Penalty
Summary
The facility failed to ensure residents were promptly informed of changes to the Nursing Home Resident Bill of Rights and failed to ensure the current RBOR was available and displayed for residents, staff, and visitors to review. During observation on 7/30/26 at 2:25 p.m., an outdated RBOR was posted in the facility. The social services director confirmed at that time that the posted RBOR information was outdated and stated it was their responsibility to hang and keep the information updated, but it had not been completed. A policy regarding posting the RBOR was requested and none was provided.
Incomplete bowel assessment and failure to share lab results with hospice
Penalty
Summary
The facility failed to comprehensively assess a change in bowel status for a resident who had dementia, was dependent for toileting with extensive assistance, and had a PEG tube in place for several years. The resident’s bowel and bladder comprehensive assessments were incomplete, with bowel observation and bowel program sections left blank, and the most recent comprehensive was not signed as completed. The annual MDS identified the resident as continent of bowel and not on a toileting program, while the care plan identified bowel incontinence and included toileting interventions. The record also showed that the resident’s bowel pattern changed, with a marked increase in loose/diarrhea stools after a period of mostly formed stools, but there was no evidence that this change was evaluated or assessed. The resident’s POC charting documented multiple bowel movements over the review period, including a shift beginning with more frequent loose stools. The MAR showed PRN laxatives were available, but there were no recorded administrations for the month. Shortly after the increase in loose stools, the resident developed vomiting and abdominal distention and was transferred to the hospital by EMS. The hospital H&P documented admission for vomiting and abdominal distention, with CT findings concerning for enteritis or partial obstruction. Interviews with nursing staff and leadership confirmed that the change in bowel consistency had not been evaluated, and the record lacked evidence of a completed bowel assessment since the prior year. The facility also failed to communicate completed lab testing and results to the resident’s hospice team. A physician ordered multiple labs, including CBC, CMP, magnesium, phosphorus, and UA, for acute confusion, and the results showed abnormal values including elevated creatinine and BUN, low RBC and hemoglobin, and a UA with probable contaminants. The hospice communication record contained visit notes, but there was no evidence the lab orders or results were shared with hospice. Hospice staff stated they were unaware the testing had been completed and would have wanted to know, while facility leadership acknowledged that hospice should have been updated with the orders and results because hospice would be involved in decisions about whether to treat abnormal findings.
Failure to Assess and Monitor New Skin Tears and Bruising
Penalty
Summary
The facility failed to ensure bruising and non-pressure wounds were adequately assessed and monitored for 2 residents reviewed for injuries of unknown origin. One resident had moderate cognitive impairment, peripheral vascular disease, and hypertension, and his medical record lacked documentation of a skin tear on his right outer wrist. He was observed with a bandage on the wrist, and when the dressing was removed the wound measured 1 cm by 0.5 cm with scant serosanguinous drainage and no signs of infection. The resident stated he had gotten the skin tear from running into a door frame, but was unsure when it occurred, and a nurse had placed a dressing on it weeks earlier. RN-A stated she was not aware of the skin tear until the state agency identified it and could not determine who applied the dressing or when it was placed. The second resident had severe cognitive impairment, hemiplegia, hemiparesis following a stroke, vascular dementia, and epilepsy. His skin issue form documented a bruise on his lower back, but the medical record lacked further documentation or monitoring of the bruise. RN-B stated the bruise was caused by a lift sheet bunched under the resident's back, but he forgot to place monitoring and forgot to complete a full assessment in the medical record. RN-A stated staff were expected to measure and document new skin issues, complete a risk management note and progress note, place monitoring orders, and update the provider, while the DON and administrator stated staff should have followed the skin policy and obtained monitoring and provider orders for new skin tears or bruising.
Failure to Complete RCAs and Adjust Supervision After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and provide adequate supervision and fall prevention for a resident with significant cognitive and mobility impairments, and failure to complete consistent root cause analyses (RCAs) after multiple falls. The resident had diagnoses including major neurocognitive disorder due to vascular disease with behavioral disturbance, severe cognitive impairment, abnormalities of gait and mobility, repeated falls, CVA with left hemiparesis, acute encephalopathy, and chronic pain. A psychiatric mental health evaluation dated 2/25/26 specifically recommended 24-hour supervision, noted that simple ADLs needed to be initiated by caregivers, and that continual supervision might be needed to correct the resident’s behaviors. Despite this, the resident’s care plan did not incorporate the recommendation for 24-hour supervision or enhanced supervision, and there was no documented reassessment of supervision needs in response to the psychiatric evaluation. The resident’s care plans addressed assistance with ADLs, including substantial/maximal assistance for toileting and transfers, use of two staff with stand assist or full mechanical lift as needed, turning and repositioning every 2–3 hours, and directions to analyze time of day, places, circumstances, triggers, and de-escalating factors for behaviors. The care plan also directed staff to assess and anticipate toileting needs, comfort, positioning, and pain. However, from February through March 2026, the medical record showed no adequate documented analysis of root causes for the resident’s repeated falls, no evidence that the interdisciplinary team revised the care plan in response to these falls, and no documentation that supervision needs were reassessed in light of the psychiatric evaluation. The facility’s own Fall Prevention and Management Policy required a falls analysis when a resident has two or more falls, to review trends, identify individual and systemic causes, and evaluate and adjust interventions, but this was not consistently carried out for this resident. Between 2/18/26 and 3/29/26, the resident experienced at least seven unwitnessed falls in various locations, including the lounge, hallway, and bedroom. Some progress notes contained limited or incomplete RCAs, while several falls had no documented RCA at all. For example, after a fall on 2/18/26 when the wheelchair became stuck near a brick wall and the resident slipped onto the pedals, the note did not identify a root cause, and interventions were limited to toileting every two hours, repositioning, lowering the bed, and ensuring the call light was within reach. A 2/25/26 fall in the hallway identified that the resident slipped due to an unused right foot pedal being down, and the intervention was to remove and store that pedal, but there was no broader analysis of other contributing factors. Subsequent falls on 3/4/26, 3/16/26 (two separate unwitnessed falls), 3/17/26, 3/18/26, and 3/29/26 lacked comprehensive RCAs in the documentation. Interviews with staff and a family member further demonstrated gaps in assessment, supervision, and communication. The family member reported not always being informed of falls, stated that the resident was supposed to be toileted every two hours but this was not consistently done, especially with agency staff, and described finding the resident incontinent, sitting alone in the pod with a wet, foul-smelling wheelchair. Nursing assistants reported that the resident frequently tried to get up without help, that staff were not always present to watch her, that she needed to be checked every two hours, and that environmental factors such as noise, loud music, or light might contribute to her falls. They also stated they were unaware of any new interventions or team discussions following the multiple falls. The LPN case manager, an RN, and the DON all acknowledged the resident was a frequent faller, were unaware of the psychiatric evaluation recommending 24-hour supervision, and confirmed that supervision levels and the care plan had not been updated despite the ongoing fall pattern and the facility policy requiring comprehensive assessment and falls analysis after multiple falls. Overall, the facility did not consistently assess or address the factors contributing to the resident’s repeated falls, did not complete or document comprehensive RCAs after multiple unwitnessed falls, did not revise the care plan to reflect the psychiatric recommendation for continuous supervision, and did not ensure staff were informed of and implementing appropriate interventions as required by the facility’s fall prevention policy.
Failure to Follow Care Plan During Transfer Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a transfer, resulting in a fall and significant injury. The resident, who had diagnoses including hypertension, atrial fibrillation, generalized weakness, and mobility impairments, required substantial or maximal assistance for transfers and mobility, as well as the use of a gait belt and appropriate footwear. On the day of the incident, a nursing assistant transferred the resident from bed to the bathroom for a weight check without providing footwear or using a gait belt, and left the resident standing unsupported on the scale. While stepping off the scale, the resident lost balance and fell, hitting her head against the wall. The fall was witnessed, and it was documented that the staff did not assist the resident during the transfer as required by the care plan. The resident was on blood thinners, which increased the risk of complications from head injuries. Following the fall, the resident exhibited increased confusion and drowsiness, and was later found to have a brain bleed confirmed by CT and MRI scans. Interviews with staff and family confirmed that the care plan was not followed during the transfer, and that the resident was left unsupported and without necessary safety measures. The incident was reported to the provider and family, and neuro checks were initiated. The failure to adhere to the care plan and established safety protocols directly led to the resident's fall and subsequent injury.
Failure to Timely Notify Physician and Representative of Resident Injury
Penalty
Summary
The facility failed to notify a resident's physician and resident representative in a timely manner following the discovery of a new skin tear injury. The resident, who had a history of traumatic subdural hemorrhage, cerebral infarction, anxiety disorder, and severely impaired cognition, was found to have a skin tear on the left lower shin while being assisted by staff. The injury was assessed and treated by a registered nurse, but the physician was not notified until two days later, and there was no evidence that the resident's representative was notified at the time of the incident. Documentation showed that the resident's representative only learned of the injury later in the day after inquiring about a bruise, and the physician's office confirmed delayed notification. Interviews with staff and review of facility procedures revealed that staff were expected to notify the physician and resident representative immediately or within the same shift when new injuries occurred. However, the nurse who discovered the injury did not complete the required notifications, citing a busy shift and incomplete charting. The incident report was not completed until later, and the facility was unable to provide a copy of its notification policy when requested. This failure to promptly notify the appropriate parties constituted a deficiency in the facility's response to resident injuries.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and findings that the required behavioral health interventions and supports were not provided to residents as needed. The lack of appropriate behavioral health care and services was directly observed and documented by surveyors during the review.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the State Agency as required. A resident, who was cognitively intact and had diagnoses of heart failure and bipolar disorder, reported feeling uncomfortable during personal care provided by a nursing assistant. The resident stated that the nursing assistant continued washing her despite her request to stop and that she felt the assistant's erection, which made her feel anxious and fearful. This incident was reported to the director of nursing nearly two days later, which was not in compliance with the facility's guidelines that require immediate reporting within two hours. The director of nursing was informed of the alleged abuse on the evening of the incident but did not become aware of the details until two days later when reviewing written statements from the staff. The facility's Maltreatment Reporting Guidelines clearly state that any allegations of abuse must be reported to the appropriate authorities immediately, but not later than two hours after the allegation is made if it involves abuse. The delay in reporting this incident to the State Agency constitutes a deficiency in the facility's adherence to these guidelines.
Failure to Notify Provider and Representative of Resident Fall
Penalty
Summary
The facility failed to notify the provider and resident representative of a fall experienced by a resident. The resident, who had diagnoses including type 2 diabetes and hypertension, rolled out of bed while attempting to reach the fridge and fell to the floor. Despite the implementation of safety measures such as a low bed and fall mat, the incident was not reported to the necessary parties as required by the facility's policy. The incident occurred during a chaotic night shift, and the floor nurse forgot to complete an incident report and notify the provider and resident representative. The facility's policy mandates immediate notification of a family member or responsible party when a resident suffers an injury due to an accident or incident. However, in this case, the notification was not carried out, leading to a deficiency in the facility's adherence to its own policies.
Failure to Follow Pressure Ulcer Care Orders and Infection Control Practices
Penalty
Summary
The facility failed to adhere to physician orders for pressure ulcer care and did not follow proper infection control practices during a dressing change for a resident with multiple pressure ulcers. The resident, who had diagnoses of peripheral vascular disease, quadriplegia, and spinal stenosis, was cognitively intact and fully dependent on staff for activities of daily living. The resident had a Stage 4 sacral pressure ulcer, an unstageable left buttock pressure ulcer, and a Stage 3 right buttock pressure ulcer, all of which were documented to have significant tissue damage and drainage. During an observation of wound care, a registered nurse (RN) did not perform hand hygiene between glove changes, which is a critical step in preventing infection. The RN also failed to apply Santyl ointment to the wound beds as ordered by the nurse practitioner, which is essential for removing dead tissue and promoting healing. The RN admitted to forgetting to perform hand hygiene and not following the physician's orders due to nervousness. The nurse practitioner emphasized the importance of following physician orders and maintaining hand hygiene to protect the wound from bacteria and ensure proper healing. The facility's administrator acknowledged that staff should adhere to care plans, orders, and the hand hygiene policy. However, the facility did not provide a policy on pressure ulcers when requested.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information, including data for agency and contract staff, to CMS for Quarter 1. During the review, it was found that the Payroll Based Journal (PBJ) report identified excessively low weekend staffing, which was not supported by the staffing schedules and daily postings for the weekends in question. Interviews revealed that the scheduler was unaware of who submitted the information, and the administrator indicated that the corporate office was responsible for the submission. A data entry error at the corporate office affected all 15 facilities, including this one, and was corrected before the next quarter's submission. No policy related to PBJ entries was available by the end of the survey.
Failure to Notify Family of Significant Changes and Death
Penalty
Summary
The facility failed to ensure timely notification of residents' family members or representatives regarding significant changes in condition, including the death of two residents. For Resident R203, the electronic health record (EHR) indicated that the resident was found unresponsive and without vital signs at 9:45 p.m., and the hospice agency was contacted at 9:51 p.m. However, there was no documentation that the family or resident representative was informed of the resident's passing. A family member reported that the facility did not contact them during the resident's decline and only informed them two hours after the resident had passed away. The Assistant Director of Nursing (ADON) confirmed that typically hospice would update the family, but no documentation of family notification was found in this case. For Resident R205, the facility also failed to notify the family timely regarding significant changes in condition and the resident's death. The EHR showed that the resident experienced weakness, shortness of breath, and was unable to bear weight, but there was no record of family notification. The resident was later found face down on the floor with facial injuries and received CPR before passing away. The family was informed about the fall and the resident's death but not about the facial injuries until the funeral home contacted them. Additionally, the family was not notified when the resident was sent to the hospital earlier. Interviews with staff confirmed the lack of timely family notification during these critical events, and the facility's policy required immediate notification of significant changes, including accidents, health deterioration, transfers, or death.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were comprehensively assessed for self-administration of medications for three residents. Resident 24, who was cognitively intact but required assistance with activities of daily living (ADLs), was observed with a nebulizer machine on her nightstand containing a solution from the morning, indicating she forgot to perform her nebulizer treatment. The medication self-administration assessment for Resident 24 indicated she could not correctly administer nebulizer medications and did not wish to self-administer medications, yet she was still left to self-administer her nebulizer treatment without proper oversight or documentation by the nursing staff as per medical doctor orders. Resident 34, also cognitively intact and requiring assistance with ADLs, was observed self-administering a nebulizer treatment without staff present. The medication self-administration assessment for Resident 34 indicated he was not able to self-administer medications and did not wish to do so. Despite this, nursing staff left the nebulizer solution for Resident 34 to self-administer at a later time, and staff only checked afterward to ensure the treatment was completed. This practice was inconsistent with the assessment and medical doctor orders. Resident 46, who had intact cognition and required assistance with all ADLs, was observed with an albuterol inhaler on his over-the-bed table and was seen using it independently. The medication self-administration assessment for Resident 46 indicated he could not correctly administer inhalant medications and did not wish to self-administer medications. Despite this, the inhaler was left within his reach, and he was observed using it without proper assessment or an order for self-administration. The facility's policy required a comprehensive assessment and an order for self-administration, which was not followed for these residents.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident or their representative at the time of hospital transfer. The resident, who was cognitively intact and required assistance with activities of daily living, was hospitalized and returned to the facility without any documented evidence that a bed hold policy was communicated. The assistant director of nursing confirmed that there was no communication regarding the bed hold for the resident's hospitalization, which is a requirement according to the facility's policy. The facility's Bed Hold Election & Hospital Transfer policy mandates that residents or their representatives be informed of the bed hold option during hospitalization or therapeutic leave. In the case of an emergency transfer, the policy requires that a copy of the notice be sent with the transfer papers and a phone call be made to the responsible party. Additionally, the policy states that documentation of this communication should be made in the resident's progress notes, and a copy of the bed hold policy should be mailed within 24 hours. This procedure was not followed for the resident in question, leading to the deficiency noted in the report.
Failure to Follow Provider Orders and Obtain Necessary Orders for Devices
Penalty
Summary
The facility failed to ensure provider orders were followed for monitoring vital signs for a resident with multiple serious diagnoses, including arteriosclerotic heart disease, hypertension, congestive heart disease, and a nontraumatic subarachnoid hemorrhage. The nurse practitioner had ordered vital signs to be taken three times daily due to the increased risk of brain bleed, but the electronic health record and the resident's closed hard chart did not show that these vital signs were recorded for three days. Interviews with the nurse consultant and the assistant director of nursing confirmed the absence of these vital signs in the electronic health record, indicating missed documentation as shown by pink boxes in the electronic medication administration record. Additionally, the facility failed to obtain a provider order for a lap positioning belt for a resident with cerebral palsy and neuromuscular scoliosis, who preferred to wear a seat belt when in his electric wheelchair. The resident's care plan and restrictive device assessment indicated the use of a lap positioning belt, but the physician orders lacked evidence of an order for this device. The assistant director of nursing confirmed that a physician's order was needed for the lap positioning seatbelt and that the facility could not locate such an order. A provider order policy was requested but not received in both cases.
Failure to Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for a resident diagnosed with PTSD, anxiety disorder, and depression. The resident's significant change Minimum Data Set (MDS) indicated cognitive intactness and required assistance with activities of daily living (ADLs). Despite a trauma assessment completed earlier, which indicated the resident had trauma affecting her daily life, the care plan lacked individualized trauma-informed approaches, identification of triggers, and interventions to avoid potential re-traumatization. Interviews with various staff members, including a nurse practitioner, trained medication assistants, and a licensed practical nurse, revealed that they were unaware of the resident's past trauma and PTSD diagnosis. The assistant director of nursing confirmed that the care plan should have included behavior monitoring, PTSD triggers, and interventions to avoid those triggers, but it did not. The facility's policy on trauma-informed care indicated that care practices should account for residents' experiences and preferences to mitigate triggers, but this was not followed in the resident's case.
Failure to Identify Irregularities in Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified irregularities in the monthly drug regimen reviews for three residents. Resident 11, who had multiple medical conditions including hypertension and depression, had an order for monthly orthostatic blood pressure monitoring while on trazodone. However, the medical record lacked evidence of this monitoring from August 30, 2023, to April 18, 2024, and there was no recommendation from the pharmacy consultant regarding this monitoring. Resident 21, who had severe cognitive impairment and was dependent on staff, had orders for psychotropic medications lorazepam and paliperidone. The medical record lacked evidence of orthostatic blood pressure monitoring, and there was no recommendation from the pharmacy consultant for this monitoring. Similarly, Resident 34, who was cognitively intact but required assistance with activities of daily living, had orders for psychotropic medications olanzapine and hydroxyzine. The medical record lacked evidence of orthostatic blood pressure monitoring and an initial assessment for abnormal involuntary movements (AIMS). Interviews with facility staff, including the nurse consultant, pharmacist, licensed practical nurse, and assistant director of nursing, confirmed the lack of monitoring and recommendations. The pharmacist admitted to missing the recommendation for orthostatic blood pressure monitoring and AIMS assessment. The facility's psychotropic medication policy did not address the need for orthostatic blood pressure monitoring, contributing to the oversight.
Failure to Monitor Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring for potential cardiovascular and neurological adverse effects in residents using psychotropic medications. Specifically, three residents were identified as not having their orthostatic blood pressures monitored as required. Resident 11, who had a complex medical history including hypertension and schizotypal disorder, had an order for monthly orthostatic blood pressure monitoring while on trazodone, but only one reading was recorded over several months. Similarly, Resident 21, with severe cognitive impairment and multiple diagnoses including cardiovascular disease and depression, also lacked evidence of orthostatic blood pressure monitoring despite being on multiple psychotropic medications. Resident 34, who was cognitively intact but required assistance with activities of daily living, also did not have orthostatic blood pressures monitored or AIMS assessments completed as required for their psychotropic medication use. Interviews with facility staff, including the pharmacy consultant, nurse consultant, and assistant director of nursing, revealed gaps in the monitoring process. The pharmacy consultant admitted to missing recommendations for orthostatic blood pressure monitoring and AIMS assessments for residents on psychotropic medications. The nurse consultant and assistant director of nursing confirmed that the facility relied on the pharmacy consultant's recommendations for monitoring and assessments, and acknowledged the absence of these critical evaluations in the residents' medical records. The facility's psychotropic medication policy did not address the need for orthostatic blood pressure monitoring, which contributed to the oversight. The policy was intended to ensure appropriate use, evaluation, and monitoring of medications to minimize risks, but it failed to include specific guidelines for monitoring orthostatic blood pressures. This lack of comprehensive policy and oversight led to the deficiency in monitoring residents for potential adverse effects from psychotropic medications.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that three residents were offered and/or provided the Influenza vaccine and/or the pneumococcal vaccine series as recommended by the CDC. Specifically, one resident declined the PCV20 and Influenza vaccines, but there was no documentation of the declination form, education, or progress note in the electronic health record (EHR). Another resident received the PCV13 but lacked evidence of shared clinical decision-making with the physician for the PCV20. The third resident received the PPSV23 but also lacked evidence of shared clinical decision-making with the physician for the PCV20. Both of these residents were not offered or provided education on the PCV20 vaccine. During an interview, the infection preventionist (IP) confirmed that immunizations are reviewed upon admission and that the CDC pneumococcal vaccine recommendations were used for eligibility. The IP verified that the two residents had not been offered or provided education on the PCV20 and that there had been no shared clinical decision-making with the provider regarding pneumococcal immunizations. The facility's policy indicated that all residents would be offered vaccinations based on CDC recommendations and physician orders, but this was not followed in these cases.
Failure to Notify LTC Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to ensure the LTC Ombudsman was notified of hospitalizations, which are considered facility-initiated discharges, for five residents. These residents were identified as having various medical conditions and required hospitalization for issues such as elevated temperature, pain, dehydration, urinary tract infection (UTI), shortness of breath, low oxygen saturations, hypotension, and other complications. Despite these hospitalizations, the medical records for these residents lacked evidence that the LTC Ombudsman had been notified as required by regulations. Interviews and document reviews revealed that the LTC Ombudsman had not received any notices of transfers or discharges from the facility for over a year. The Ombudsman had previously discussed this issue with the facility's administrator and activity director. Additionally, the facility's nurse consultant confirmed that they could not locate records indicating that the LTC Ombudsman had been notified of the transfers and/or discharges. The facility's policy on Transfer and Discharge from Facility was requested but not provided, further highlighting the deficiency in compliance with notification requirements.
Failure to Annually Review Infection Control Policies
Penalty
Summary
The facility failed to review and/or revise its infection control program's policies and procedures at least annually, potentially affecting all 51 residents, staff, and visitors. During a review of the facility's infection control policies, it was found that several policies had not been reviewed or amended for several years. For instance, the 'Infection Surveillance' policy had not been reviewed since 2017, and the 'Resident Tuberculosis Prevention and Control' policy had not been reviewed since 2019. Other policies, such as the 'COVID-19 Vaccination' and 'Antibiotic Stewardship Program,' also had outdated review dates, indicating a lack of regular updates and reviews as required by regulations. Interviews with the infection preventionist (IP), assistant director of nursing (ADON), and nurse consultant (NC) revealed that the facility relied on corporate policies and did not conduct individual annual reviews of these policies. The IP and ADON were unaware of the requirement to review the policies annually, while the NC confirmed that the quality team reviewed and amended policies as needed but did not include infection control policies in their recent review. This oversight in policy review and revision could lead to outdated practices and potential risks for infection control within the facility.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner, which compromised the dignity of two residents. One resident, identified as R8, had moderately impaired cognition and required substantial assistance with toileting. On multiple occasions, R8's call light was not answered promptly, leading to prolonged waiting times of up to 62 minutes. During this period, R8 experienced discomfort and had urine accidents due to the delay in assistance. Observations revealed that staff members either ignored the call light or were too busy to provide immediate help, resulting in R8 feeling neglected and afraid of falling when attempting to get up by herself. Another resident, identified as R9, also experienced delays in call light response. R9, who had intact cognition but required assistance with toileting due to limited mobility, reported waiting up to 45 minutes for help. This delay led to instances of incontinence, causing R9 to feel ashamed and embarrassed. Observations confirmed that R9 had to wait for assistance while her roommate, R8, was using the shared bathroom, further highlighting the inadequacy of the facility's response to call lights. Interviews with staff members, including nursing assistants and the assistant director of nursing, revealed that the expected response time for call lights was 15 minutes. However, the actual response times observed were significantly longer, failing to meet the facility's policy. The facility's policies on call light response and maintaining resident dignity were not adhered to, resulting in adverse events and a lack of timely assistance for the residents' toileting needs.
Failure to Respond to Call Lights Timely
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in providing necessary assistance. Resident R8, who had moderately impaired cognition and required substantial assistance with toileting, experienced multiple instances where her call light was not answered promptly. On several occasions, R8 had to wait over 20 minutes, and in one instance, over an hour, for assistance to use the bathroom. This delay caused R8 to have urine accidents, leading to discomfort and fear of falling when attempting to get up by herself. Observations confirmed that staff walked past R8's room without responding to her call light, and even when staff did respond, they were unable to assist her immediately due to the unavailability of necessary equipment like the lift. Resident R9, who had intact cognition but required assistance with toileting due to limited mobility and a history of urinary tract infections, also experienced delays in call light responses. R9's call light activity report showed multiple instances where the call light was not answered for over 20 minutes, and in some cases, up to 45 minutes. R9 reported feeling ashamed and embarrassed due to incontinence episodes caused by the delays in receiving assistance. Observations and interviews with staff confirmed that the expected response time for call lights was not being met, with staff citing a lack of sufficient personnel to address all call lights promptly. Interviews with nursing assistants and other staff members revealed that the facility's policy required call lights to be answered within 15 minutes to ensure resident safety and dignity. However, the actual response times frequently exceeded this limit, leading to residents' needs not being met in a timely manner. The assistant director of nursing and the floor manager both acknowledged the importance of prompt call light responses and the negative impact of delays on residents' well-being. The facility's failure to adhere to its call light policy resulted in residents experiencing unnecessary discomfort, incontinence, and a lack of timely assistance with toileting needs.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R3) who was dependent on staff for assistance due to a recent hip fracture. R3's care plan required toileting every two to three hours, but during an observation, it was found that R3 had not been checked or changed for almost seven hours. R3 was found with a large amount of stool and urine in his brief, indicating that the scheduled toileting plan was not followed. The nursing assistants (NA-A and NA-C) confirmed that they were short-staffed, which led to the delay in providing the necessary care. Interviews with the nursing assistants and a registered nurse revealed that R3 had recently undergone hip surgery and was no longer independent, requiring more assistance with activities of daily living. The staff acknowledged that R3 should have been checked and changed multiple times during the day but were unable to do so due to staffing issues. The facility's failure to adhere to the scheduled toileting plan resulted in R3 remaining in soiled briefs for an extended period, which was confirmed by the observations and staff interviews.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for a resident with moisture-associated skin damage (MASD). The resident, who had multiple medical conditions including peripheral vascular disease, cerebral vascular accident, and chronic obstructive pulmonary disease, was at high risk for skin breakdown as indicated by a Braden assessment score of 11. The resident had a physician order to cleanse the buttocks daily and apply Med-honey with an adhesive foam dressing, but this order was not consistently followed. Observations revealed that the wound dressing was often saturated, and inappropriate materials such as peri wipes were used to clean the wound, which is not designed for wound care and could spread germs instead of cleaning the wound effectively. The resident's wound showed signs of deterioration, including increased tunneling and a strong foul odor, indicating possible infection. Staff were observed using improper techniques, such as packing the wound with their fingers instead of using a small cotton swab, and failing to use the prescribed wound cleaner. The wound continued to worsen, with moderate serosanguinous drainage and a significant amount of slough present. Despite the resident's refusal to reposition, which likely affected the healing process, the staff did not adhere to the physician's orders or the facility's protocols for wound care. Interviews with the nursing staff and the assistant director of nursing revealed a lack of awareness and adherence to the proper wound care procedures. The staff did not follow the physician's orders and failed to verify or seek clarification when the appropriate supplies were not available. The facility's policy required the use of wound cleaner and proper packing techniques, but these were not followed, leading to the worsening of the resident's wound condition.
Failure to Implement Influenza A Infection Control Procedures
Penalty
Summary
The facility failed to implement recommended influenza A infection control procedures for the use of personal protective equipment (PPE), specifically masks, during direct care with residents. This deficiency was observed in two residents who tested positive for influenza A. Despite the presence of contact precaution signs, there was no mention of droplet precautions or the requirement for masks, which are essential to prevent the spread of influenza A. Staff members were observed entering and exiting the rooms of these residents without wearing the necessary PPE, such as masks and gowns, even though the residents were frequently coughing and unable to cover their mouths, increasing the risk of infection spread. One resident tested positive for influenza A and was observed multiple times lying in bed with a frequent loose cough. The contact precaution sign outside the resident's room did not mention the need for masks, and staff members were seen entering the room with inadequate PPE. For instance, an LPN entered the room wearing only gloves and no mask or gown while performing wound care, despite the resident's continuous coughing. Another resident also tested positive for influenza A and was observed sitting in a recliner with the door open and a contact precaution sign that did not mention masks. Staff members were seen entering the room without the required PPE, even though the resident had a frequent loose cough. Interviews with staff members, including nursing assistants and registered nurses, revealed a lack of clarity and adherence to the facility's infection control policies. Staff members acknowledged that droplet precautions, including the use of masks, should have been implemented immediately upon confirmation of influenza A. However, the appropriate signs and PPE usage were not enforced, leading to potential exposure and spread of the infection. The facility's policy on standard and droplet precautions clearly outlined the need for masks when dealing with infections like influenza A, but these guidelines were not followed in practice.
Failure to Notify Resident Representative and Physician of Falls
Penalty
Summary
The facility failed to ensure that the resident representative and physician were notified of falls with and without injuries for one resident reviewed for accidents. The resident, who had diagnoses including dementia and anxiety disorder, experienced multiple falls on various dates. The facility's documentation lacked evidence of notification to the resident's representative or physician for these incidents. Specific falls occurred on 8/8/23, 8/10/23, 8/14/23, 8/20/23, 8/24/23, 9/10/23, 9/19/23, 9/28/23, 10/6/23, and 10/13/23, with no documented notifications to the resident's representative or physician. Additionally, progress notes for falls on 9/19/23, 9/28/23, 10/6/23, and 10/13/23 also lacked evidence of such notifications. Interviews with the registered nurse (RN) and the director of nursing (DON) confirmed that the nursing staff who completed the incident reports were expected to notify the resident's representative and physician following each fall, regardless of injury. The facility's policy required immediate notification of the family or responsible party in case of injury and within a reasonable time frame if there was no injury. The policy also mandated immediate physician notification for injuries or medical treatment and within a reasonable time frame for other events. The RN and DON confirmed that these notifications were not documented for the specified falls, indicating a failure to adhere to the facility's policy.
Failure to Monitor and Treat UTI Symptoms
Penalty
Summary
The facility failed to comprehensively assess and implement continuous monitoring for signs and symptoms of a urinary tract infection (UTI) and notify the physician timely with a change in condition and/or worsening symptoms for one resident. The resident had diagnoses including dementia, anxiety disorder, and benign prostatic hyperplasia (BPH), and required intermittent catheterization. The care plan lacked evidence of being at risk for UTIs or staff direction on monitoring for UTI signs and symptoms. Despite the resident showing signs of a UTI, such as hematuria, increased confusion, and tiredness, the facility did not implement the UTI protocol or notify the physician promptly. On multiple occasions, staff noted the resident's symptoms, including hematuria, increased confusion, foul-smelling urine, and back pain. However, there was no evidence of additional monitoring or timely notification to the physician. The resident's temperature was not recorded until two days after the initial symptoms were noted. The facility's policy required obtaining vital signs every shift and reassessing for UTI symptoms once identified, but this was not followed. The resident's condition worsened, and they were eventually taken to the emergency department, where they passed away. Interviews with staff revealed that they were aware of the resident's symptoms but did not follow the facility's UTI protocol. The Director of Nursing (DON) confirmed that the UTI protocol was not implemented and that the physician was not notified of the resident's condition until it had significantly worsened. The facility's policy required a thorough assessment and monitoring for UTI symptoms, but this was not done, leading to a delay in treatment and the resident's subsequent hospitalization and death.
Failure to Re-assess and Revise Care Plan for Cognitively Impaired Resident with Multiple Falls
Penalty
Summary
The facility failed to comprehensively re-assess and revise a resident's care plan, who was cognitively impaired and had multiple falls resulting in minor injuries. The resident had diagnoses including dementia and anxiety disorder, and was noted to have severely impaired cognition. Despite multiple falls, the care plan lacked evidence of implemented interventions to prevent further falls. The resident's care plan included interventions such as a low bed with fall mats and staff assistance with proper footwear, but these were not consistently implemented or updated following each fall. The resident experienced several unwitnessed falls, and the interdisciplinary team (IDT) discussed the incidents but failed to ensure that the interventions were documented and implemented in the care plan. For instance, after a fall on 8/10/23, the IDT determined that the resident should sleep in his bed at night with the bed low and floor mats down, but this intervention was not reflected in the care plan. Similarly, after a fall on 8/20/23, the IDT decided that the resident should be laid in bed after supper unless restless, but this intervention was also not documented in the care plan. Additionally, the facility's staff failed to complete incident reports, root cause analyses, and IDT reviews for several falls. Progress notes for falls on 9/19/23, 9/28/23, 10/6/23, and 10/13/23 lacked evidence of incident reports, root cause analyses, or care plan revisions. Interviews with staff revealed that they were not aware of all the fall interventions or the need for safety or hourly checks. The facility's policies on accident/incident reporting and fall prevention were not followed, leading to a lack of comprehensive re-assessment and revision of the resident's care plan to prevent further falls.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to identify target behaviors, revise care plans to include non-pharmacological interventions, and monitor effectiveness for three residents who were prescribed scheduled psychotropic medications. Resident 1 had a diagnosis of depression and was prescribed sertraline, but there was no evidence of behavior monitoring, target behaviors, or non-pharmacological interventions in the care plan. Similarly, Resident 2, who had a diagnosis of depression and exhibited verbal behavioral symptoms, was prescribed Cymbalta without evidence of behavior monitoring or target behaviors in the care plan. Resident 3, diagnosed with Parkinson's Disease and depression, was prescribed Venlafaxine, but the care plan lacked evidence of target behaviors and non-pharmacological interventions. The Director of Nursing confirmed that the medical records for all three residents lacked evidence of target behaviors identified in the care plan and monitoring of behaviors to determine unnecessary psychotropic medication use. The facility's policy on psychotropic medications required the primary care physician to identify target behavior symptoms and for nursing staff to monitor psychotropic drug use daily, noting any adverse effects and the presence of target behaviors. Social Services was expected to develop a behavioral care plan, but this was not done for the three residents reviewed.
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Illustrative
What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Little Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Ottos Care Center | 1 mi | ★★★★★ | 1 | 0 |
| Pierz Villa Inc | 11.7 mi | ★★★★★ | 7 | 0 |
| Sartell Therapy Suites | 23.6 mi | — | 0 | 0 |
| Cura Of Long Prairie | 24.3 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Woodland | 25.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.