Little Falls Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

immediately as well.On 8/21/25 at 4:40 p.m., attempted interview with Resident R1's provider was unsuccessful.On 8/22/25 at 8:56 a.m., DON stated staff were expected to complete an incident report upon discovering a new skin impairment, and part of the document required staff to notify the physician and resident representative. DON stated RN-D discovered the skin tear in the early morning of 8/10/25 and passed on in report to the next shift because RN-D was unable to complete all tasks due to having a busy night. DON stated RR was upset she was not notified.On 8/22/25 at 9:59 a.m., RN-D stated at approximately 5:30 a.m.

on 8/10/25, RN-D was paged to go to Resident R1's room and RN-D observed the skin tear. RN-D stated she assessed the wound and passed through report to the next shift of the update. RN-D stated she was not completed with her charting at 6:30 a.m. when her shift was over, so RN-D returned to the facility later that afternoon to complete the incident report. RN-D stated she was aware she did not notify Resident R1's resident representative and I am sure [RR] was not happy, and RN-D confirmed she did not notify Resident R1's physician because, it all happened so fast. Further, RN-D stated notifying the physician and resident representative was part of completing the incident report, and staff were expected to call nurse triage and leave a message for the resident's physician and notify the resident's representative.On 8/26/25 at 11:30 a.m., return call from RN-E, nurse at Resident R1's physician's office, RN-E confirmed the provider was not notified of Resident R1's skin tear until a note was received from the facility a couple days later about a wound dressing.A copy of

the facility's notification policy was requested but facility failed to provide.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Little Falls Care Center

1200 First Avenue Northeast Little Falls, MN 56345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bottom, unlocks lift brakes and brings Resident R1 into the bathroom. NA-B then maneuvered Resident R1 out of the bathroom in the lift and opens the lift legs over Resident R1's wheelchair, locks the lift brakes and directs Resident R1 to stand, paddles are removed and Resident R1 sits down in her wheelchair. On 8/21/25 at 2:06 p.m., Resident R1 was sitting in her wheelchair in her room and stated she was able to walk just fine to and from the bathroom with a cane, but Resident R1 was unsure why the staff were using a lift instead. Resident R1 stated I am afraid to ask they would tell me something I don't want to hear. On 8/21/25 at 2:25 p.m. NA-B stated all NA's have access to each resident's care plan which would identify what each resident's transfer status and ADL assistance was. If there were changes to a resident's care plan the changes were communicated through verbal report at change of shift.

Further, NA-B stated Resident R1 required a non-mechanical sit to stand lift always and Resident R1 was able to ambulate with a walker and a gait belt. On 8/21/25 at 2:59 p.m., NA-C stated Resident R1 required staff assistance with all ADLs and transferred with a non-mechanical sit to stand lift. NA-C stated Resident R1 was not able to ambulate that

she was aware of. On 8/21/25 at 3:15 p.m., RN-C staff were expected to review the communication board in

the facility's electronic medical record (EMR) system for changes and updates to a resident's care plan, however RN-C stated she was made aware recently some staff were not aware of how to do it so RN-C changed the process as of 8/21/25, and will now have a binder to communicate updates. Further, RN-C stated Resident R1 was able to stand and pivot with assist of one staff to transfer using a gait belt and was able to ambulate with a cane. RN-C was not aware staff were utilizing a non-mechanical sit to stand lift to transfer Resident R1 and no staff had reported any concerns or changes with Resident R1's transfers. RN-C stated Resident R1's transfer status was revised on 8/9/25. In addition, RN-C stated staff would be expected to report any changes or concerns and if a resident refuses staff should be documenting. On 8/22/25 at 8:56 a.m., director of nursing (DON) stated Resident R1's care plan was recently revised to ambulate Resident R1 to and from the bathroom with assist of one staff and Resident R1 was a stand and pivot transfer. DON stated staff were expected to report changes or concerns with

a resident's transfer status to the case managers on the unit so the team was aware and could revise the care plan. Further, DON stated all staff would be expected to carry the electronic tablets and reference each resident's plan of care they are assisting. A copy of the facility's care plan policy was requested but facility failed to provide.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Little Falls Care Center

1200 First Avenue Northeast Little Falls, MN 56345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

director of nursing (DON) stated Resident R1 had exhibited behaviors since admitting to the facility, but the behaviors appeared to increase when there was an infection. DON stated staff were expected to monitor effectiveness of psychotropic medications and track behaviors. Each resident would be expected to have target behaviors

in their treatment record for staff to document as well as in the resident care plan with interventions for staff to implement if a resident was exhibiting behaviors.A copy of the facility's behavior and psychotropic medication policy was requested but facility failed to provide.

Event ID:

Facility ID:

If continuation sheet