Central Todd County Care Center
CENTRAL TODD COUNTY CARE CENTER in CLARISSA, MN — inspection on October 29, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
245521 10/29/2025
Central Todd County Care Center 406 East Highway 71 Clarissa, MN 56440
hospital nurse was documented R1 was baseline with transfers and pivot.
Since we had no issues
condition/quarterly/annually.
The fall risk assessment was most likely not done on R1. R1 tripped
readmitted .
During an interview on 10/29/25 at 12:57 p.m., registered nurse (RN)-C stated 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 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. R1 fell and resulted in fractures, therapy should have been contacted and assessed 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.
245521 10/29/2025
Central Todd County Care Center 406 East Highway 71 Clarissa, MN 56440
During a fall like R1's where a gait belt was not used and resident started to fall the staff would most likely have reached out and grabbed onto an upper extremity or completed a bear hug, and any of those could have resulted in injury especially with the geriatric population. R1 had a degenerative joint disease and would have caused a higher risk for injury without a gait belt which resulted in other means used to break the fall.
NA-A was expected to have used a gait belt when R1 was transferred and could have made a difference, her shoulders would have not been affected, and NA-A's hand position would have been different.
Education was initiated after the incident on 10/13/25 and 10/14/25 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, but 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.
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 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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.