Little Falls Care Center: Care Plan Failures - MN
The resident, identified in inspection records only as R1, told inspectors that staff had been using a mechanical lift to move them to the bathroom, even though the resident believed they could walk there with a cane. "I am afraid to ask," R1 said. "They would tell me something I don't want to hear."
What inspectors found when they asked staff was not reassurance. It was contradiction.
One nursing assistant said R1 needed a non-mechanical sit-to-stand lift at all times and could walk with a walker and gait belt. A second nursing assistant said R1 needed the lift for transfers and could not walk at all, as far as she knew. The charge nurse said R1 could stand and pivot with one staff member and a gait belt and could walk with a cane. She had no idea staff were using a mechanical lift and said no one had reported any concerns.
The care plan had been revised on August 9, two weeks before the inspection. The charge nurse acknowledged recently learning that some staff did not know how to check the facility's electronic medical record system for care plan updates. Her response, as of August 21, was to start a binder.
The director of nursing told inspectors that staff were expected to carry electronic tablets and check each resident's care plan before providing assistance. She said staff should report transfer concerns to case managers so the team could update the plan. Inspectors requested a copy of the facility's care plan policy. The facility did not provide one.
The inspection was filed as a complaint. The level of harm was listed as minimal harm or potential for actual harm, affecting few residents.
R1 spent that time being moved by equipment they didn't need, by staff who couldn't agree on what their care plan said, afraid to ask a question that might have cleared it up in sixty seconds.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
LITTLE FALLS CARE CENTER in LITTLE FALLS, MN was cited for violations during a health inspection on August 22, 2025.
"They would tell me something I don't want to hear." What inspectors found when they asked staff was not reassurance.
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.