Little Falls Care Center: Physician Not Notified of Injury - MN
The inspection at Little Falls Care Center, completed August 22, 2025, documented what happened when a nurse's busy night became a reason to skip required steps, and what that meant for the resident and the people who were supposed to be kept informed.
At approximately 5:30 a.m. on August 10, 2025, a registered nurse identified in the report as RN-D was paged to a resident's room. She found a skin tear. She assessed the wound. Then, according to her own account to inspectors, she passed word to the next shift through report and left when her shift ended at 6:30 a.m., her charting still unfinished.
She did not call the resident's physician. She did not notify the resident's representative, the family member or other designated person responsible for staying informed about the resident's condition. She knew both calls were required. She said it all happened so fast.
RN-D returned to the facility later that afternoon to complete the incident report she hadn't finished before leaving. By then, hours had passed since the wound was found. The physician still had not been reached.
The director of nursing told inspectors that staff were expected to complete an incident report upon discovering any new skin impairment, and that the document itself required staff to notify the physician and the resident representative. Notification wasn't a separate step someone might remember to do. It was built into the paperwork. RN-D confirmed she understood that. She confirmed she had not done it.
When inspectors reached the nurse at the physician's office, identified as RN-E, the account from the clinical side was plain. The provider was not notified of the skin tear until a note arrived from the facility, a couple of days later, about a wound dressing. Not a phone call about a new injury. A note, days later, about a dressing change.
The director of nursing told inspectors that the resident's representative was upset she had not been notified. RN-D, in her interview, said she was sure the representative was not happy.
What the inspection report captures is a gap that widened with each hour: a wound found before dawn, a shift that ended without the required calls being made, a physician who learned about the injury only incidentally, and a family member left to find out she hadn't been told at all.
RN-D's explanation to inspectors was that she had a busy night, that she was behind on charting, that it all happened fast. The director of nursing offered a partial explanation as well: RN-D had passed the information on in report to the next shift, because she was unable to complete all tasks due to having a busy night.
Passing information in shift report is not the same as calling the physician. It is not the same as calling the family.
Inspectors requested a copy of the facility's notification policy. The facility did not provide one.
The resident's representative learned after the fact that she had not been told about a skin tear found on the person she was designated to speak for. The physician's office learned about the injury from a note about a dressing. RN-D went home and came back later to finish the paperwork.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's assessment of what was documented. It does not describe what it is like to be the family member who finds out, after the fact, that something happened to your person and nobody called.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
Little Falls Care Center in LITTLE FALLS, MN was cited for violations during a health inspection on August 22, 2025.
on August 10, 2025, a registered nurse identified in the report as RN-D was paged to a resident's room.
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.