Little Falls Care Center: Care Plan Failures Harm Resident - MN
She wasn't wrong to be confused. Her care plan had been updated on August 9, 2025, more than two weeks before the inspection, changing her transfer status to a stand-and-pivot with one staff member assisting, using a gait belt. She could ambulate with a cane. The mechanical sit-to-stand lift was no longer part of her care.
Nobody told the nursing assistants.
When inspectors visited on August 21, a nursing assistant identified as NA-B described the resident's transfer method as a non-mechanical sit-to-stand lift, always, and said the resident could walk with a walker and a gait belt. A second nursing assistant, NA-C, told inspectors the resident required staff assistance with all activities of daily living and transferred with a non-mechanical sit-to-stand lift. NA-C said she was not aware the resident could walk at all.
Both descriptions were out of date. Both nursing assistants believed they were working from accurate information.
The registered nurse on the unit, identified as RN-C, said the resident could stand and pivot with one staff member assisting, using a gait belt, and could ambulate with a cane. She had no idea staff were still using the lift. No one had reported a concern. No one had flagged a change. RN-C told inspectors she had only recently learned that some staff did not know how to access the communication board in the facility's electronic medical record system, where care plan updates were supposed to appear. As of August 21, the day inspectors were on site, she had changed the process. There would now be a binder.
The director of nursing told inspectors that staff were expected to carry electronic tablets and reference each resident's plan of care during every shift. Staff were expected to report changes or concerns to case managers so the team could revise care plans accordingly.
The care plan had been revised. The team had not been made aware.
What inspectors observed on August 21 was a nursing assistant performing a full mechanical lift transfer on a resident who, by the facility's own updated records, should have been walking to the bathroom. The assistant approached with the lift, positioned it, unlocked the brakes, maneuvered the resident into the bathroom, then brought her back out, opened the lift legs over the wheelchair, locked the brakes again, and directed the resident to sit down. The resident sat.
She was capable of walking. She had been walking, she told inspectors, just fine.
The care plan policy inspectors requested was never provided by the facility.
The violation was cited at the level of minimal harm or potential for actual harm. The finding reflects a breakdown not in any single staff member's judgment but in the facility's system for moving updated information from a revised care plan to the people responsible for carrying it out. Two nursing assistants working from the same outdated understanding, a nurse unaware of what was happening on her own unit, a process that had quietly failed and was only corrected the day inspectors arrived.
The resident had been sitting in her wheelchair that afternoon, uncertain why the lift kept coming, certain enough about something to decide not to ask.
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.
She wasn't wrong to be confused.
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.