Three Links Care Center: Lift Fall Breaks Resident's Femur - MN
The fall happened on September 12, four days before inspectors arrived. The resident, identified in inspection records only as R1, was being transferred using a full-body mechanical lift when he fell. Imaging confirmed a new transverse fracture of the right femur, the large bone running from hip to knee. The facility's orthopedic physician told inspectors the fall from the lift most definitely caused the fracture, and that it put R1 at risk for serious harm and did cause serious harm, specifically because the injury required surgery.
A transverse fracture runs straight across the bone at a right angle to its length. According to the Cleveland Clinic, transverse fractures are typically caused by falls or car accidents. They are not the kind of injury that happens from routine wear.
The inspection report does not describe in detail exactly what went wrong during the transfer. What it does confirm is that the sling and lift used for R1's transfer were removed from service immediately after the fall, pending inspection for malfunction. It also confirms that on the same day R1 was sent to the emergency room, two nursing assistants, identified as NA-A and NA-B, underwent return demonstration competency testing on safe mechanical lift use. The timing raises a direct question the inspection report does not answer: why were staff being retested on lift safety the same day a resident was taken to the hospital with a broken femur, rather than before the transfer that broke it?
The facility's own mechanical lift policy, dated May 28, 2025, required staff to use appropriate techniques and processes when operating mechanical lift devices, specifically to protect the safety and well-being of residents. That policy was in place for more than three months before R1 fell.
What inspectors found in the aftermath pointed toward a specific and correctable failure in how slings were being attached or identified. The facility's immediate response included color-coding the sling loops with tape so staff could identify the correct attachment points during transfers. The plan called for a mechanical lift manufacturer's representative to visit on September 23 to review the policy and provide hands-on education to all nursing staff. Every resident using a similar sling had the correct loops marked with colored tape before inspectors left. Every resident using a mechanical lift had their sling inspected and their care plan reviewed to confirm the right sling size was documented.
The color-coding fix is significant. It suggests the problem was not simply that staff were careless. It suggests the correct loops on the sling were not clearly distinguishable from the wrong ones, and that without a visual marker, a nursing assistant performing a transfer could attach the sling incorrectly without immediately knowing it. Whether that ambiguity was a design flaw in the equipment, a gap in training, or both, the inspection report does not say.
The facility's fall prevention policy, dated June 5, 2023, required the interdisciplinary team to evaluate every fall through a root cause analysis and to document any new interventions. The immediate jeopardy was not lifted until inspectors verified the facility had taken specific corrective steps: the emergency room visit, the removal of the lift and sling from service, the competency retesting of NA-A and NA-B, the color-coding system, the review of all residents on mechanical lifts, and the scheduled manufacturer education. Only after all of that was confirmed did inspectors move the citation from immediate jeopardy to a lower level, designated in inspection records as past noncompliance.
That designation matters. Past noncompliance means the facility is no longer in violation at the time of the survey, because it has implemented sufficient corrective action. It does not mean the harm did not occur. R1 had already been sent to the hospital. The fracture had already happened. The surgery was already necessary.
Mechanical lifts are used in nursing homes precisely because they are supposed to be safer than manual transfers. For residents who cannot bear their own weight, a mechanical lift is often the only way to move them from a bed to a wheelchair, to a toilet, to a shower, without risking injury to the resident or the staff member. When a lift is used correctly, with the right sling, attached at the right points, with straps checked for proper tension, it distributes the resident's weight evenly and keeps them secure throughout the transfer. When something goes wrong, the resident has no way to catch themselves. They are suspended, dependent entirely on the equipment and the person operating it.
The inspection report notes that the facility's re-education for nursing staff included manufacturer recommendations for full-body mechanical lift use, specifically checking straps for tension and confirming proper sling size against the care plan. Those are not advanced or obscure steps. They are the basic checklist for a safe transfer. The fact that they became the subject of emergency retraining after a resident's femur was broken suggests they were not being consistently followed before September 12.
Three Links Care Center is a nursing facility in Northfield, a city of roughly 20,000 people about 35 miles south of Minneapolis. The inspection was a complaint survey, meaning it was triggered by a report filed with the state, not a routine scheduled visit. The inspection report does not identify who filed the complaint or what it alleged.
R1's care plan was to be updated upon his return from the hospital, with a reassessment of the proper sling size for future transfers. The inspection report does not say when he was expected to return, or what his condition was beyond the fracture and the need for surgery. It does not say whether he had family present, whether anyone was with him when he fell, or what he or anyone else said about the moment the lift failed.
What the record shows is a man who needed help moving from one place to another, who depended on staff and equipment to do that safely, and who left his nursing home in an ambulance with a broken bone in his leg.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Links Care Center from 2025-09-19 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 23, 2026 · Our methodology
THREE LINKS CARE CENTER in NORTHFIELD, MN was cited for violations during a health inspection on September 19, 2025.
The fall happened on September 12, four days before inspectors arrived.
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.