Central Todd County Care Center: Fall Care Failures - MN
The resident, identified in inspection records only as R1, had been sent to the hospital after a fall. When she returned to Central Todd County Care Center that weekend, none of the office staff were present. The floor nurse received a telephone report from the hospital indicating R1 was "at baseline" with transfers. That was enough. Staff continued using one to two people to assist with stand-pivot transfers, applied a gait belt, and did not call therapy.
Nobody reassessed her. Nobody documented a readmission assessment. The fall risk assessment, the Director of Nursing later acknowledged, "most likely was not done."
R1 had dementia and poor short and long-term memory. She also had degenerative joint disease, which the Director of Nursing told inspectors would have increased her injury risk without a gait belt. But the gait belt created its own problem: a registered nurse reviewing the case later told inspectors she "would have been concerned with the gait belt applied in close proximity of her fractured ribs would not be the safest either."
That concern was never raised at the time. Because nobody had assessed R1 when she came back.
The Director of Nursing told inspectors that readmissions over weekends were unusual. When R1 returned, the office was empty and the receiving nurse relied entirely on the hospital's report that she was at baseline. "Since we had no issues with how she transferred over the weekend," the DON said, "staff continued with assist of one to two staff and therapy was not involved."
The licensed practical nurse who took the hospital's telephone report told inspectors she was "unaware if a therapy assessment was completed at the hospital or upon readmission." She had told the hospital nurse, before the fall, that R1 needed extensive assistance of one to transfer. The hospital nurse said R1 transferred the same way in the hospital and was "most likely at baseline." That phrase, relayed over the phone, became the entire clinical basis for how staff handled a woman with fresh fractures.
The facility's own transfer policy, dated October 2025, required reassessment after any change in condition and after any fall or injury. Its falls policy required a safety assessment on all new admissions, quarterly, and "as needed." Neither was followed.
Inspectors requested the facility's readmission assessment policy. It was never provided. They also requested any therapy evaluation from the hospital. That was never provided either.
RN-C, a registered nurse at the facility, told inspectors she found the whole situation troubling. R1 had returned from the hospital with fractures. The idea that she could be at baseline struck the nurse as odd. "Seemed odd she could have been back to baseline with transfers," she said, adding she was "unsure if it was a good idea to have one assist with a gait belt." She said therapy should have been contacted immediately so staff could transfer R1 in a way that accounted for her injuries.
Why the readmission checklist was never completed, she couldn't explain. "Most likely got missed," she said.
The inspection, a complaint survey, was completed October 29, 2025. Inspectors cited the deficiency at a level of minimal harm or potential for actual harm.
A woman with broken ribs was being lifted by a belt cinched around her midsection. The nurses who later reviewed her care said it shouldn't have happened that way. The ones who were there when she returned said they followed what the hospital told them. The assessment that would have resolved the question was never done.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Central Todd County Care Center from 2025-10-29 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 23, 2026 · Our methodology
CENTRAL TODD COUNTY CARE CENTER in CLARISSA, MN was cited for violations during a health inspection on October 29, 2025.
The resident, identified in inspection records only as R1, had been sent to the hospital after a fall.
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.