Little Falls Care Center
LITTLE FALLS CARE CENTER in LITTLE FALLS, MN — inspection on August 22, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
of 8/10/25 and passed on in report to the next shift because RN-D was unable to complete all tasks
observed the skin tear. RN-D stated she assessed the wound and passed through report to the next
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 R1's resident representative and I am sure [RR] was not happy, and RN-D confirmed she did not notify 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 R1's physician's office, RN-E confirmed the provider was not notified of 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.
245399 08/22/2025
Little Falls Care Center 1200 First Avenue Northeast Little Falls, MN 56345
bathroom with a cane, but R1 was unsure why the staff were using a lift instead. R1 stated I am
status and ADL assistance was. If there were changes to a resident's care plan the changes were
non-mechanical sit to stand lift always and R1 was able to ambulate with a walker and a gait belt. On 8/21/25 at 2:59 p.m., NA-C stated R1 required staff assistance with all ADLs and transferred with a non-mechanical sit to stand lift. NA-C stated 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 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 R1 and no staff had reported any concerns or changes with R1's transfers. RN-C stated 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 R1's care plan was recently revised to ambulate R1 to and from the bathroom with assist of one staff and 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.
245399 08/22/2025
Little Falls Care Center 1200 First Avenue Northeast Little Falls, MN 56345
words at another resident.
Resident was then [NAME] down to other wing to completely change
involvement, took for ride in wheelchair around inside of the building, offered snack and drink which
One to one distraction did not seem to be effective, and resident would continue to have weeping episodes.-On 7/19/25, resident was yelling out for help, thinks resident was trying to kill us thinking she had to clean something up.
Distraction, toileting and one to one with the nurse was attempted but was not effective.-On 7/17/25, resident was wheeling into other rooms yelling at others saying, I'm going to kill you, I have the power.
Staff separated then resident was calling multiple staff killers and that she had all the power.-On 7/16/25, Resident awoke at 0300 yelling out from her room.
Resident yelling get her out of here or I will, then began making threats to nursing assistant of [NAME] staff if she wasn't removed.
Resident was unconsolable at that time.
Distraction was unsuccessful with the use of TV show, food/beverage, etc.-On 7/11/25, resident was roaming the pod aimlessly searching for random items such as the sewer stating, I'm going to blow it up. I have a finger that will do it.
Behavior was unable to be redirected.
Resident continued to push herself backwards in her wheelchair throughout the hallway and pods, talking nonsensical statements to self and others as they walked by.On 8/20/25 at 3:52 p.m., registered nurse (RN)-A stated R1 exhibited behaviors of yelling and ramming around in here, and R1 would often resist cares such as toileting especially at night. RN-A stated staff would attempt to offer distraction of coloring, drink, food, bathroom, one to one staffing but there were only so much non-pharmacological interventions that are effective.On 8/21/25 at 12:00 p.m., nursing assistant (NA)-A stated R1 exhibited behaviors such as yelling, swatting at staff, crying, and will self-propel around the unit with no sense of direction and would run into things.On 8/21/25 at 1:46 p.m., R1 was observed to be tearful and stating her daughter did not care about her, and NA-B would offer reassurance and offered toileting.
Interventions were only effective a short while, and NA-B was observed to be tearful again.On 8/21/25 at 2:25 p.m., NA-B stated R1's cognition was impaired and R1 had some forgetfulness and confusion. NA-B stated later afternoon/evenings R1 would often get anxious and agitated and would cuss out staff or have some delusions about a shooter and interventions of distraction was often not effective.
Further, NA-B stated these behaviors were R1's baseline and the behaviors appeared to be constant.On 8/21/25 at 2:59 p.m., NA-C stated R1 exhibited behaviors through out the night such as hollering, attempting to go into other resident's rooms and staff would offer snack, warm towels, sit with R1, read her a magazine to attempt to calm R1 and these behaviors have been R1's baseline since NA-C started working at the facility.On 8/21/25 at 3:15 p.m., RN-C stated R1 exhibited behaviors of hollering, verbal combativeness with staff and threatening to kill you. RN-C stated these behaviors have been R1's baseline and typically occur in the evenings, but at times do increase in frequency with an infection.
RN-C stated staff are expected to chart resident behaviors in the resident treatment record and resident care plan would be expected to reflect target behaviors to monitor as well as person-centered interventions to implement. RN-C confirmed there were no target behaviors listed in R1's care plan and there was no treatment order for staff to monitor or document R1's behaviors to review for psychotropic medication effectiveness, which R1 was prescribed Trazodone.On 8/22/25 at 8:56 a.m., director of nursing (DON) stated 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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.