Three Links Care Center: Lift Sling Fall Fractures Resident - MN
Federal inspectors cited the facility for immediate jeopardy, the most serious level of harm under Medicare and Medicaid oversight, following a complaint inspection completed September 19, 2025.
The fall happened on September 12. The resident, identified in inspection records only as R1, was being transferred using a full-body mechanical lift when the sling gave way. The sling involved had two sets of black loops, one set at the top and one set lower on the sling, and the correct loops to use depended on the resident's size and care plan. The nursing assistants, identified as NA-A and NA-B, used the wrong set.
The assistant director of nursing described what happened when inspectors re-created the transfer using the two different loop lengths: a tension release, and then the sling came off the arm of the lift entirely. She told inspectors she was 99 percent sure the incorrect loops were used, and that this is why R1 fell to the ground. She also acknowledged she had not known, before the fall, that this type of sling had two sets of black loops and that using the wrong set could create exactly this kind of risk.
That detail sits at the center of what inspectors found. The equipment had a design feature, two sets of nearly identical black loops, that created a real possibility of error. Staff were using it. Nobody had flagged the hazard.
R1's primary care physician told inspectors on September 18 that any resident falling from a mechanical lift at a height of two feet would be at risk for serious injury. Four days after the fall, on September 16, R1 had a scheduled follow-up appointment with an orthopedic surgeon. The surgeon learned during that visit that R1 had fallen from a mechanical lift. Imaging was done of R1's right hip and right femur. The results showed a new transverse fracture of the femur, the large bone running from the hip to the knee, the kind of break typically associated with falls or car accidents.
The orthopedic surgeon told inspectors the fall from the lift most definitely caused the fracture. R1 needed surgery.
The facility's own mechanical lift policy, dated May 28, 2025, less than four months before the fall, stated that staff would use appropriate techniques and processes when utilizing mechanical lift devices to protect the safety and well-being of residents. The fall prevention policy, dated June 2023, called for the interdisciplinary team to evaluate any fall through a root cause analysis and to document whatever interventions were developed.
What the inspection record does not show is that anyone had previously identified the two sets of black loops as a confusion risk and built a safeguard around it. The color-coding fix, marking the correct loops with colored tape, came after R1 was already on the floor.
After the fall, the facility moved quickly. R1 was sent to the emergency room the same day. The sling and lift were pulled from use pending inspection. NA-A and NA-B completed return demonstration competency testing on September 12, the day of the fall. The facility reviewed every resident using a similar sling and had the correct loops marked with colored tape on each one. Care plans were checked. Re-education on mechanical lift procedures, including checking strap tension and using the correct sling size, began that same day across the nursing staff.
The facility also scheduled a visit from a mechanical lift manufacturer's representative for September 23 to review the policy and provide education to all nursing staff.
Inspectors noted all of this and issued the immediate jeopardy citation at what is called "past noncompliance," meaning the facility had already put corrective steps in place before the survey team arrived. That designation does not erase the citation or the underlying harm. It means the jeopardy to other residents had been addressed by the time inspectors completed their review. R1's fractured femur remained.
Mechanical lift injuries in nursing homes are not rare events that emerge from nowhere. The lifts exist because residents cannot bear their own weight safely during transfers, which means a failure in the lift system drops someone who is already among the most physically vulnerable people in the building. The margin for error is close to zero, and the consequences when something goes wrong are immediate and often severe.
The specific failure here, two sets of loops that look alike, both black, both on the same sling, with no marking to distinguish them before the fall, is the kind of hazard that tends to persist until something goes wrong. The assistant director of nursing said plainly that she had not known the sling worked this way. If the person overseeing nursing assistants did not know, there is no reason to assume the nursing assistants did either.
The facility's policy said to use appropriate techniques. It did not, apparently, describe what to do when the sling itself has a built-in ambiguity that appropriate technique alone cannot resolve.
R1 went to the emergency room on September 12. He saw the orthopedic surgeon on September 16 for what had been scheduled as a routine follow-up. He left that appointment with a surgery ahead of him and a fractured femur that, according to the surgeon, would not have been there if the sling had been attached correctly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Links Care Center from 2025-09-19 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: June 27, 2026 · Our methodology
Three Links Care Center in NORTHFIELD, MN was cited for violations during a health inspection on September 19, 2025.
The fall happened on September 12.
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.