Central Todd County Care Center: Transfer Fall Violation - MN
The resident, identified in inspection records as R1, used an EZ stand and required assistance with transfers. A gait belt was the standard equipment for that kind of move. The nursing assistant, referred to as NA-A, did not apply one.
R1 fell forward.
In an interview with inspectors on October 28, NA-A said she had positioned herself the way she did because she believed it was the best approach. She also acknowledged it wasn't safe. "Where she stood was not safe," the inspection report notes, "and should have maybe stood on R1's side instead." If R1 had continued falling forward, NA-A told inspectors, she most likely could not have stopped it.
The Director of Nursing told inspectors that R1 had dementia and poor short and long-term memory. R1 also had degenerative joint disease, which the inspection report identifies as a condition that significantly raises injury risk when a gait belt is not used. Without the belt, if a resident begins to fall, a staff member's instinct is to grab an arm or wrap the resident in a bear hug. Either response, the report states, can cause serious injury in elderly patients. The absence of the gait belt meant that R1's shoulders were affected in ways they would not have been had the belt been in place.
The facility's own administrator told inspectors that the gait belt was listed under "safety equipment" in R1's records but was not identified as such on the care plan or Kardex, the quick-reference document nursing staff use at the bedside. The Director of Nursing said staff were expected to use gait belts for any resident requiring transfer assistance, and that this expectation did not need to be spelled out explicitly because the Kardex would indicate assistive devices like walkers or EZ stands, and any such resident would require a belt. The logic assumed staff would make the connection. R1's fall suggests at least one staff member did not.
After the incident, the facility launched corrective training on October 13 and 14. Staff received education through an online health academy system, written policy documents, text messages, and audits checking whether gait belts were being applied before transfers. The training covered the belt itself. It did not cover where a staff member should stand during a transfer, or how to execute one safely.
That gap was addressed later with a new audit form. The form told staff where to position themselves: on the resident's strong side.
That was wrong.
The Director of Nursing told inspectors he had misread the guidance. Staff should stand on the resident's weak side. The inspection report notes that staff were left confused by the inaccurate instruction. The correction, when it came, arrived after staff had already been operating under the wrong information.
Inspectors cited the violation as causing actual harm. The inspection, prompted by a complaint, was conducted on October 29, 2025.
The facility's own fall safety policy, dated October 2025, states that residents are to be evaluated for physical devices that could reduce falls and injuries, and that those findings are to be reflected in the care plan with specific interventions for staff to follow. Its transfer policy, also dated October 2025, describes a stand-pivot transfer, the type used with R1, as requiring one to two staff with a gait belt secured at the waist.
The belt was not secured. The resident fell. The retraining that followed told staff to stand on the wrong side.
R1's shoulders bore the difference.
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: 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 6, 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 as R1, used an EZ stand and required assistance with transfers.
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.