Little Falls Care Center: Behavior Plan Failures - MN
That was one day among many. On July 16, she woke at 3 a.m. screaming, threatening a nursing assistant, inconsolable through television, food, and drink. On July 17, she rolled into other residents' rooms yelling that she was going to kill them, that she had all the power. On July 19, she screamed for help, convinced she had to clean something up, certain someone was trying to kill her. On July 24, she wept and said she might as well be dead. One-to-one distraction did not seem to be effective, and she would continue to have weeping episodes.
She was prescribed Trazodone, a psychotropic medication. Her care plan had no target behaviors listed. There was no treatment order for staff to monitor or document her behaviors. Nobody was tracking whether the medication was working.
That finding sits at the center of an August 22 complaint inspection at Little Falls Care Center, a nursing facility in central Minnesota. The resident, identified in inspection records only as R1, had been exhibiting these behaviors since she was admitted. Multiple staff told inspectors the behaviors were her baseline, meaning they were not new, not escalating in any surprising way, just constant.
A nursing assistant identified as NA-B described the pattern plainly: later afternoons and evenings, R1 would get anxious and agitated, cuss out staff, or have delusions about a shooter. Distraction was often not effective. NA-B called it R1's baseline.
NA-C, who worked nights, said R1 would holler, attempt to enter other residents' rooms, and require staff to sit with her, offer snacks, bring warm towels, read her a magazine. NA-C said this had been R1's baseline since NA-C started working at the facility.
A registered nurse identified as RN-C confirmed what the inspection records would later document directly: there were no target behaviors listed in R1's care plan, and there was no treatment order requiring staff to monitor or document her behaviors, which would be the mechanism for evaluating whether Trazodone was doing anything at all. RN-C said staff were expected to chart behaviors and that the care plan would be expected to reflect target behaviors, but confirmed neither existed for this resident.
The director of nursing told inspectors on August 22 that R1 had exhibited behaviors since admission and that they appeared to increase with infection. The director said staff were expected to monitor psychotropic medication effectiveness and track behaviors, and that each resident should have target behaviors in their treatment record as well as interventions in their care plan. The director did not explain why R1 had neither.
Inspectors requested a copy of the facility's behavior and psychotropic medication policy. The facility did not provide one.
What the inspection record captures across those weeks is a woman in sustained distress, and a staff that was trying, in the ways available to them, to help. Nursing assistants sat with her. They offered coloring. They brought snacks and warm towels and magazines. They took her on wheelchair rides through the building. RN-A told inspectors there were only so many non-pharmacological interventions that are effective, and that R1 would often resist cares like toileting, especially at night.
That is not a staff that was ignoring a resident. It is a staff working without a plan, without documented targets, without a way to tell a physician or a pharmacist whether the medication in this woman's chart was helping or not.
On August 21, at 1:46 in the afternoon, inspectors observed R1 crying, saying her daughter did not care about her. NA-B offered reassurance and toileting. The interventions worked for a short while. Then NA-B was observed to be tearful again.
Forty minutes later, NA-B told inspectors that R1's cognition was impaired, that she had forgetfulness and confusion, and that the behaviors had been constant.
The inspection was filed as a complaint, meaning someone contacted regulators about conditions at the facility before inspectors arrived. The report does not say who filed the complaint or what specifically prompted it.
What it does say is that a resident spent the better part of the summer threatening staff, weeping, ramming her wheelchair through hallways, and telling people she might as well be dead, while the document that was supposed to guide her care left those behaviors unnamed and unmeasured.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Little Falls Care Center from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 8, 2026 · Our methodology
LITTLE FALLS CARE CENTER in LITTLE FALLS, MN was cited for violations during a health inspection on August 22, 2025.
screaming, threatening a nursing assistant, inconsolable through television, food, and drink.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.