Central Todd County Care Center: Fall Investigation Failures - MN
He was wrong about almost all of it.
A federal inspection completed October 29th, 2025, at Central Todd County Care Center found that the facility's investigation into the incident was incomplete, that the education provided to staff contained a critical error, and that the director of nursing had given nurses incorrect instructions about how to stand during resident transfers, then later admitted he had mixed up which side of a resident staff should position themselves on.
The nursing assistant involved, identified in inspection records only as NA-A, had transferred a resident without using a gait belt. The gait belt, a wide strap fastened around a resident's midsection, is a standard tool used during transfers to give staff a secure hold and reduce the risk of a fall. The director of nursing was not on site when the incident occurred over the weekend. He returned Monday, interviewed NA-A, and concluded the missing gait belt was the cause.
He did not complete a root cause analysis. He acknowledged to inspectors that one should have been done and that he still planned to do one, but had not. He also acknowledged the problem could have been more than just the gait belt.
Only one resident was interviewed during the investigation. That was R1, the resident directly involved. No other residents cared for by NA-A were interviewed, despite the facility's own policy requiring that the individual conducting an abuse or neglect investigation interview other residents to whom the accused employee provides care and services.
The education that went out to all nursing staff on October 13th and 14th covered gait belt application and whether it was applied before transfers. It went out through a computer system, through documents, through texts. What it did not cover was where staff should stand during a transfer, or how to physically execute a safe transfer once the belt was in place. The director of nursing told inspectors he thought proper positioning would just come naturally from using the gait belt correctly.
It did not.
Staff were later given a new audit form that included instructions on where to stand during transfers. The instruction was to stand on the resident's strong side. That was wrong. The director of nursing told inspectors he had misinterpreted the guidance and that staff should have been told to stand on the weak side, the side where a resident is more likely to lose balance or bear less weight. For an unknown stretch of time, nurses and aides at the facility were transferring residents while positioned on the wrong side, following instructions their own director had given them in error.
The inspection report does not specify how many transfers were conducted under the incorrect guidance, or whether any residents were harmed during that period.
The gap between what the investigation found and what it missed runs through the entire record. The director identified the gait belt as the problem. He started audits on NA-A. He provided education. He checked the box on each step and, as he told inspectors, thought they were doing good. The root cause analysis that might have surfaced the positioning error, or identified whether other staff had similar gaps in their training, was never completed.
The facility's own policy, dated October 17th, 2025, four days after the investigation began, states that all resident incident reports must be reviewed by the Quality Assurance Committee and the Medical Director, and that the interdisciplinary team will review all incident reports for potential allegations of abuse. The policy on abuse investigations states that employees accused of participating in alleged abuse will be immediately reassigned to duties that do not involve resident contact or suspended without pay until findings are reviewed. Whether those steps were taken in this case is not addressed in the inspection record.
What the record does show is a facility that identified a narrow cause, built its response around that narrow cause, and sent staff back to work with instructions that turned out to be incorrect. The director of nursing told inspectors he had misread the guidance on which side to stand. He told them a root cause analysis should have been done. He told them the education lacked information on positioning and safe transfer technique. He said all of this in the past tense, to a federal inspector, weeks after the incident.
Central Todd County Care Center is a small facility in rural Todd County, in central Minnesota. Clarissa has a population of a few hundred people. Facilities like this one often serve residents who have no realistic alternative for care within their community. When a transfer goes wrong in a place like this, the question is not just what happened in that moment but what the facility does in the weeks that follow to make sure it does not happen again.
The inspection found the answer here was: not enough.
The gait belt audits on NA-A showed no further issues. The director told inspectors he had not recalled any problems and thought things were on track. But the audit form being used at that point did not ask about positioning. It asked about the belt. The tool designed to catch the problem was not designed to catch the whole problem.
By the time inspectors arrived on October 29th, the facility had been operating for more than two weeks under a corrective plan that contained a factual error about basic transfer safety. Staff had been told the wrong thing. Some of them may have been standing on the wrong side of residents, residents who depend on that positioning to stay upright, for the entire time between the incident and the inspection.
The director of nursing said he still planned to complete the root cause analysis.
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.
He was wrong about almost all of it.
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.