Central Todd County Care Center: Fall Assessment Failure - MN
The resident, identified in inspection records only as R1, had fallen and sustained fractures before being readmitted to Central Todd County Care Center. When she returned, staff continued using a gait belt and one- to two-person assists for transfers, the same approach used before the fall. Nobody had completed a fall risk reassessment.
During an interview on October 29, 2025, registered nurse C told the inspector that R1 should have been assessed upon readmission from the hospital. "We are usually really good about that," the nurse said. "Unsure why that was not done, most likely got missed."
The nurse went further. She said she would have been concerned about applying a gait belt near fractured ribs, calling it not the safest approach. She also said it seemed odd that someone with new fractures could have returned to baseline on transfers, and that therapy should have been contacted to determine the safest way to move R1 given her injuries.
The facility's own transfer policy, dated October 2025, states that residents are to be reassessed after any fall, near fall, or injury, and that transfer methods are to account for clinical condition and therapy evaluation. The fall safety policy requires a new assessment any time there is a change in condition.
Neither was done.
Inspectors requested the facility's readmission assessment policy and the hospital's therapy evaluation for R1. Neither was provided.
The nurse's own words captured what the records left blank. A resident came back broken, and the question of how to safely move her, where to place the belt, whether one person was enough, went unasked until an inspector arrived and started asking it instead.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 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 fallen and sustained fractures before being readmitted to Central Todd County Care Center.
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.