Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Ottos Care Center during CMS and state inspections, most recent first.
A facility failed to notify the designated State Mental Health Authority for a resident with new mental health diagnoses, including major neural cognitive deficits and severe recurrent major depressive disorder with psychotic features. The social worker was unaware of these diagnoses and did not update the resident's health record or contact the county for a resident review, as required by the facility's admission policy.
A facility failed to process provider orders for a resident with a change in mental status. The resident, diagnosed with Alzheimer's and major depressive disorder, had new diagnoses that were not listed in their medical record. The facility's process involved the health unit coordinator printing provider notes for review by the RN, but the diagnoses were not processed, contrary to facility policy.
The facility failed to implement interventions to prevent decreased range of motion for two residents. One resident with moderate cognitive impairment and diabetes had AROM programs completed as required on only two out of sixty days, with no documentation explaining the inconsistency. Another resident with multiple diagnoses, including coronary artery disease and hemiplegia, had ROM programs completed as required on only a few occasions, with no explanation for the lack of completion other than occasional refusals. Staff interviews revealed inconsistent execution and documentation of ROM programs.
A facility failed to monitor orthostatic blood pressures and obtain a baseline AIMS assessment for a resident upon initiation of an antipsychotic medication. Despite the resident's history of orthostatic hypertension and facility policies requiring such monitoring, these assessments were not completed, as confirmed by staff interviews.
Failure to Notify Authorities of Resident's New Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the designated State Mental Health Authority (SMHA) for a resident with a new onset of mental illness. The resident, admitted on April 17, 2024, had a history of intact cognition and required assistance with all activities of daily living. Diagnoses included hypertension, diabetes mellitus, depression, and major depressive disorder. A psychiatric provider visit on September 12, 2024, identified new mental health diagnoses, including major neural cognitive deficits secondary to Alzheimer's with behavioral disturbance and severe recurrent major depressive disorder with psychotic features. Despite these new diagnoses, the facility did not update the resident's health record or notify the county for a resident review. The social worker was unaware of the new mental health diagnoses and confirmed that no new diagnoses were entered into the resident's health record. Consequently, no follow-up with the county was completed. The Senior Linkage Line representative indicated that a resident review was necessary due to the significant change in the resident's mental health symptoms. The facility's admission policy requires the social worker to ensure proper preadmission screening and follow-up on any mental health needs, which was not adhered to in this case.
Failure to Process Provider Orders for Resident with Mental Status Change
Penalty
Summary
The facility failed to ensure that provider orders were processed for a resident who was reviewed for a change in mental status. The resident, who had intact cognition and required assistance with all activities of daily living, was diagnosed with multiple conditions including hypertension, diabetes mellitus, and major depressive disorder. The psychiatric provider noted that the resident had major neural cognitive deficits secondary to Alzheimer's with behavioral disturbance and severe recurrent major depressive disorder with psychotic features. Despite these diagnoses, they were not listed in the resident's medical record. The facility's process for handling provider visit notes involved the health unit coordinator printing the notes, which were then reviewed by the registered nurse on duty. However, the diagnoses were not processed or listed in the resident's current diagnoses, as confirmed by the director of nursing and assistant director of nursing. This oversight was contrary to the facility's policy, which required that physician orders be transcribed and inputted into the electronic medication administration record, ensuring completeness and accuracy of the resident's medical information.
Failure to Implement ROM Interventions for Residents
Penalty
Summary
The facility failed to implement interventions to prevent further development of decreased range of motion (ROM) for two residents, R5 and R10, who were reviewed for positioning and mobility. R5, who had moderate cognitive impairment and diabetes, was recommended to perform lower extremity (LE) exercises and active range of motion (AROM) programs to maintain performance and prevent decline. However, documentation showed that R5's AROM programs were completed twice daily on only two out of sixty days reviewed, with no documentation explaining why the programs were not completed as planned. Similarly, R10, who was cognitively intact and had multiple diagnoses including coronary artery disease, heart failure, and hemiplegia, was recommended a restorative program of ROM to prevent contractures. The care plan indicated that AROM and passive range of motion (PROM) programs should be completed 3-4 times a week, twice daily. However, documentation revealed that these programs were completed as required on only a few occasions, with no explanation for the lack of completion other than occasional refusals. Interviews with staff indicated a lack of consistent execution and documentation of the ROM programs, with assumptions made about other staff completing the tasks.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to implement and monitor orthostatic blood pressures and obtain a baseline AIMS (abnormal involuntary movement scale) assessment with the initiation of an antipsychotic medication for a resident reviewed for antipsychotic medications. The resident, who had intact cognition and required assistance with all activities of daily living, had diagnoses including hypertension, diabetes mellitus, depression, and major depressive disorder. The resident's physician orders included Rexulti, an antipsychotic medication, which was started and then increased in dosage. However, the medical record lacked evidence of orthostatic blood pressures and AIMS assessment being initiated or obtained. Interviews with the consultant pharmacist, registered nurse, and the director of nursing confirmed that orthostatic blood pressures and a baseline AIMS assessment should have been initiated upon the start of the antipsychotic medication to monitor for side effects. The facility's policies indicated that these assessments were necessary to monitor for side effects such as postural hypotension, which could increase the risk of falls. Despite these policies, the assessments were not completed for the resident, who had a history of orthostatic hypertension, highlighting a deficiency in the facility's adherence to its own protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Little Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Little Falls Care Center | 1 mi | ★★★★★ | 6 | 0 |
| Pierz Villa Inc | 12.5 mi | ★★★★★ | 6 | 0 |
| Sartell Therapy Suites | 23.2 mi | — | 0 | 0 |
| Cura Of Long Prairie | 23.6 mi | ★★★★★ | 1 | 0 |
| Benedictine Living Community Mother Of Mercy | 25 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.