Clarkfield Care Center: Missing Hospice Care Plan - MN
The resident, identified as R7, was admitted to hospice services on February 26 with a terminal diagnosis of senile degeneration of the brain. He had severe cognitive impairment, was legally blind from macular degeneration, and required maximal assistance with daily activities. A wheelchair was needed for his mobility.
Despite being on hospice for more than a month, the facility never received the required care plan that would detail what services hospice would provide and what remained the nursing home's responsibility.
When inspectors interviewed staff in early April, the gaps became clear. A trained medication aide said she knew the resident was on hospice services but wasn't aware of any hospice schedule or care plan. She thought there might be some information at the nursing station, but couldn't locate it.
A licensed practical nurse confirmed the resident was still receiving hospice services, but said the frequency of visits had decreased because he was improving. She noted that a hospice nurse was supposed to visit on Monday but hadn't shown up. The nurse didn't know why the visit was missed or when it would be rescheduled.
"There was not a schedule to identify visits," according to the inspection report.
The facility's own care plan noted the resident was on hospice but failed to specify what services hospice would provide or what services remained the facility's responsibility. This left staff operating without clear guidance about the division of care duties.
The licensed practical nurse explained that hospice staff couldn't document directly in the facility's electronic medical records. Instead, they provided verbal updates to facility staff and later faxed copies of their visit notes, which were then scanned into the system.
When inspectors spoke with the hospice registered nurse the next day, she confirmed the resident had been improving and hadn't needed pain medication or comfort care recently. Hospice had reduced visit frequency after discussing his improved status at their interdisciplinary team meeting.
But she acknowledged a critical failure: "A schedule and integrated care plan should have been developed and provided to the facility at the time of admission, but that had not occurred."
The hospice nurse promised to immediately provide a copy of the care plan to the facility.
Inspectors also discovered that basic documentation was missing. The agreement detailing what services and equipment hospice would provide should have been kept in a binder at the nursing station. When facility staff were asked to produce it, nothing could be found.
The director of nursing told inspectors she expected hospice documentation to clearly identify responsibilities for services and equipment that hospice was supposed to provide. This information should have been included in the care plan provided when the resident was first admitted to hospice services.
When inspectors requested the facility's policy for hospice services, it wasn't provided by the end of the survey.
The case illustrates how coordination failures between nursing homes and hospice providers can leave vulnerable residents without clear care plans. The resident had multiple serious conditions including hypertension, dementia, malnutrition, anxiety disorder, and depression, in addition to his terminal brain condition.
Federal regulations require nursing homes to arrange for hospice services and ensure proper coordination of care. The facility's failure to obtain and maintain the hospice care plan left staff uncertain about their responsibilities for a resident in his final stage of life.
The resident required total assistance with activities of daily living except eating, which required setup help. Without a clear care plan delineating responsibilities, staff couldn't ensure all his complex needs were being met appropriately.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clarkfield Care Center from 2026-04-08 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 13, 2026 · Our methodology
Clarkfield Care Center in CLARKFIELD, MN was cited for violations during a health inspection on April 8, 2026.
The resident, identified as R7, was admitted to hospice services on February 26 with a terminal diagnosis of senile degeneration of the brain.
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.
Frequently Asked Questions
- What happened at Clarkfield Care Center?
- The resident, identified as R7, was admitted to hospice services on February 26 with a terminal diagnosis of senile degeneration of the brain.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in CLARKFIELD, MN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Clarkfield Care Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 245551.
- Has this facility had violations before?
- To check Clarkfield Care Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.