Central Todd County Care Center

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

following dates: October 13th and 14th, 16th, 17th, 20th, 21st, 22nd, 23rd, 25th, 26th, 27th, and 28th.

Monday morning, October 13th, 2025, between 7:00 a.m. and 8:00 a.m. he interviewed NA-A and realized

a gait belt was not used during the transfer. Education was provided that morning regarding the use of a gait belt during transfers and position of the staff during a transfer was not discussed, thought that would just come with the proper usage of the gait belt. He was not working on site over the weekend and returned to work on Monday, October 13th, 2025. Investigation was initiated and gait belt audits were started on 10/13/25. Gait belt audits were completed on NA-A and had not recalled any issues so thought we were doing good. A root cause analysis was not completed. After NA-A was interviewed he determined the lack of using the gait belt was the problem but could have been more than that. A root cause analysis should have been done and stilled planned on doing one. Resident R1 was interviewed. No other residents were interviewed for this investigation. Education was initiated after the incident on 10/13/25 and 10/14/25 for all nursing staff and provided through the health academy computer system, documents (policy), texts, and audits on application of the gait belt, if it was applied before transfers. The education lacked information on where to stand and how to provide a safe transfer. The staff were informed later with a new audit form where to stand

during the transfers, on the resident's strong side. Staff were confused due to inaccurate information provided such as informed of the wrong side to stand on during transfer. DON stated he had misinterpreted as strong side and should have indicated weak side.Facility policy Resident Accidents/Incidents dated 10/17/25, identified all accidents/incidents involving residents must be reported to the DON and/or the administrator. The facility inter-disciplinary team will review all incident reports for potential allegations of abuse. All resident incident reports involving residents are recorded in the point click care system for review by Quality Assurance Committee and Medical Director.Facility policy Protection of Residents During Abuse Investigations dated 10/17/25, identified our facility will protect residents from harm during investigation of abuse allegations. During the abuse investigation, employees accused of participating in the allege abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by the administrator.Facility policy Alleged Abuse Investigations dated 10/17/25, identified all reports of resident alleged abuse, neglect and injuries of unknown source shall be promptly reported and if additional investigation was required facility management will initiate an investigation of the incident. The individual conducting the investigation will take the following steps as appropriate: interview other resident to who the accused employee provides care and services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Central Todd County Care Center

406 East Highway 71 Clarissa, MN 56440

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

instead.During an interview on 10/28/25 at 2:15 p.m. Licensed practical nurse (LPN)-B stated Resident R1's cognition was not the best and had a poor memory. Resident R1 transferred with extensive assistance of one to two staff stand/pivot. On 10/11/25, she had received report via telephone from the hospital staff nurse prior to Resident R1's readmission back to the facility that day. She informed the hospital nurse prior to her fall the day before

she required extensive assistance of one to transfer. The hospital nurse indicated she transferred in the hospital the same and most likely meant she was at baseline. LPN-B stated she was unaware if a therapy assessment was completed at the hospital or upon readmission back to the facility.During an interview on 10/28/25 at 3:30 p.m., DON stated Resident R1 had dementia and poor short/long term memory. Resident R1 had a degenerative joint disease which would have caused a higher risk for injury without a gait belt which would have provided another means used to break the fall. A nurse-to-nurse report was completed prior to Resident R1's readmission to the facility from the hospital. Generally speaking, the readmissions usually do not take place over the weekends however, this one did, none of the office staff were here when she returned. The staff nurse would have been expected to have completed a readmission assessment and documented it. When

a resident returns back from the hospital and not at baseline therapy would have gotten involved. The report received from the hospital nurse was documented Resident R1 was baseline with transfers and pivot. Since we had no issues with how she transferred over the weekend staff continued with assist of 1 to 2 staff and therapy was not involved. A fall risk assessment was expected to be completed if there was a change in condition/quarterly/annually. The fall risk assessment was most likely not done on Resident R1. Resident R1 tripped over her feet when she fell on [DATE REDACTED] and was at baseline when she returned from the hospital and readmitted .During an interview on 10/29/25 at 12:57 p.m., registered nurse (RN)-C stated Resident R1 should have been assessed upon re-admission from the hospital after her fall with fractures. We are usually really good about that, unsure why that was not done, most likely got missed. RN-C stated the nurse was expected to fill out a return from hospital check list/template on the facility electronic medical record (EMR). RN-C stated she would have been concerned about Resident R1's fractures and seemed odd she could have been back to baseline with transfers, unsure if it was a good idea to have one assist with a gait belt. RN-C stated she would have been concerned with the gait belt applied in close proximation of her fractured ribs would not be the safest either. Resident R1 fell and resulted in fractures, therapy should have been contacted and assessed Resident R1 so that staff would transfer her the safest and most appropriate way with fractures and injuries.Facility policy Staff Assisted Resident Transfer dated October 2025, identified the facility will assess each resident and determine the safest transfer method for both resident and staff safety. Resident specific data will be used to determine the method of transfer including but not limited to resident preference, history, clinical condition, physician restrictions, therapy assessment (physical and occupational), and nursing assessment.

Resident will be assessed for initial transfer method determination on admission will be per resident

interview and admission documentation. Resident will then be re-evaluated after a change in condition and

after any transfer related incident (fall, near fall, injury). A stand pivot transfer where resident could weight bear on legs required assist of one to two staff with a gait belt secured on waist, scoot to edge of chair/bed, stand pivot to adjacent destination surface.Facility document Resident Falls dated October 2025, identified fall safety assessment is completed on all new admissions, quarterly, and as needed to assist in determining risk for falls. The resident is evaluated for physical devices to be used to help reduce falls, injury, or incidents. Those at risk for falls or have physical devices will be addressed in the care plan with approaches/interventions to be followed.Requested readmission /assessment policy and not received.Requested hospital therapy assessment/evaluation and not received.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Central Todd County Care Center

406 East Highway 71 Clarissa, MN 56440

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

transfer. DON stated he had misinterpreted as strong side and should have indicated weak side.During an

interview on 10/29/25 at 4:22 p.m., administrator stated safety equipment indicated gait belt but was not identified as such on the resident's care plan/Kardex. ,Staff were expected to use a gait belt during Resident R1's transfer/fall incident on 10/10/25, and a gait belt was not applied. Gait belt use was a standard of care for resident and staff safety. Facility policy Staff Assisted Resident Transfer dated October 2025, identified the facility would assess each resident and determine the safest transfer method for both resident and staff safety. Resident specific data will be used to determine the method of transfer including but not limited to resident preference, history, clinical condition, physician restrictions, therapy assessment (physical and occupational), and nursing assessment. Resident would be assessed for initial transfer method determination on admission will be per resident interview and admission documentation. Resident will then be re-evaluated after a change in condition and after any transfer related incident (fall, near fall, injury). A stand pivot transfer where resident could weight bear on legs required assist of one to two staff with a gait belt secured on waist, scoot to edge of chair/bed, stand pivot to adjacent destination surface.Facility document Resident Falls dated October 2025, identified fall safety assessment is completed on all new admissions, quarterly, and as needed to assist in determining risk for falls. Identified, the resident is evaluated for physical devices to be used to help reduce falls, injury, or incidents. Those at risk for falls or have physical devices were addressed in the care plan with approaches/interventions to be followed.

Event ID:

Facility ID:

If continuation sheet