Little Falls Care Center

In the surveyor’s words

From the most serious findings on record at Little Falls Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 16, 2022

  Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1), who was identified as an elopement risk, and was found outside the facility in a snowbank during inclement weather, from elopement. This resulted in an immediate jeopardy (IJ) situation. The IJ began on 2/6/22, when it was identified R1 had eloped from the facility and was found outside in a snowbank during inclement weather. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 2/15/22 at 2:00 p.m. […]

• Actual harm, isolatedF755Jul 30, 2026

  Based on interview and document review, the facility failed to implement a system to ensure medications were consistently acquired, received, and administered as ordered for 3 of 3 residents (R20, R4, R22) reviewed. As a result, R20 did not receive hydromorphone (synthetic opioid/narcotic) for seven days and pregabalin (anticonvulsant to treat nerve pain) for four days. This resulted in actual harm when R20 experienced severe withdrawal symptoms.Findings include: R20 R20's annual Minimum Data Set (MDS), dated [DATE], indicated R20 was cognitively intact. […]

• Actual harm, isolatedF689Dec 31, 2025

  Based on interview, and document review, the facility failed to follow the care plan to ensure safe transfers to eliminate/reduce the risk of an accident during a transfer for 1 of 3 residents (R1). This resulted in actual harm when R1 fell, sustained a significant head injury (brain bleed) that required hospitalization. The facility had implemented actions to prevent reoccurrence prior to the survey; therefore, the citation was issued at past non-compliance (PNC).Findings include:Findings include:R1's order summary report 9/2/25, indicated R1's diagnoses included primary hypertension, persistent atrial fibrillation, prediabetes, generalized weakness, chronic respiratory failure, abnormalities of gait and mobility.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had… […]

• No harm, potential for more than minimal, widespreadF851Jul 30, 2026

  Based on observation, interview, and document review, the facility failed to consistently include the facility census on the daily nurse staff posting. This had the potential to affect all 60 current residents, their families and visitorsThe facility's Staffing Data Submission Payroll Based Journal (PBJ), noted the facility was triggered for survey review of Low Weekend Staffing and Licensed Nurses for 24 hours per day during the 1st quarter of 2026 for the following dates:Saturday 10/26/25Saturday 11/29/25Saturday 12/13/25Sunday 12/14/25Sunday 12/28/25 In addition, the facility's Staffing Data Submission Payroll Based Journal (PBJ), noted the facility was triggered for survey review of Licensed Nurses for 24 hours per day during the 2nd quarter of 2026 for the following dates:Saturday… […]

• No harm, potential for more than minimal, widespreadF880Jul 30, 2026

  Based on observation, interview, and document review, the facility failed to implement proper infection control procedures when handling soiled linens. This had the potential to affect all residents who used facility laundered linens. Findings include: During observation and interview on 7/29/26 at 1:14 p.m. laundry aide (LA)-F stated the process for laundry services. LA-F stated soiled laundry was sorted by towel, blankets, etc and by unit. LA-F stated they only wear gloves for sorting soiled linens. The gowns hanging in the room were only for COVID. During interview on 7/29/26 at 1:29 p.m. Environmental services director (ES)-G stated his expectation was staff wore gloves and gowns when sorting soiled linens. […]