Three Links Care Center
Three Links Care Center in NORTHFIELD, MN — inspection on September 19, 2025.
Found 1 citation. 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 an interview on 9/19/25 at 11:37 a.m., orthopedic surgeon medical doctor (OS-MD) stated R1 had been seen on 9/16/25, for a scheduled follow-up and had been informed R1 had a fall from a total mechanical lift four days prior. R1 had imaging done of right hip and right femur and was found to have a new transverse (according to the Cleveland Clinic a transverse fracture are a type of broken bones, usually caused by falls or car accidents) fracture of the femur. OS-MD further stated, most definitely the fall from the lift caused the fracture of R1's femur and put him at risk for serious risk for harm and did cause serious harm for R1 due to needing surgery.
Review of the facility's Mechanical Lift Policy dated 5/28/25, identified facility staff would use appropriate techniques and processes when utilizing mechanical lift devices to lift and move residents, to protect the safety and well-being of staff and residents, to promote quality care, and to follow applicable laws regarding use of power-driven mechanical lifts.
Review of the facility's Fall Prevention and Management Policy dated 6/5/23, identified The interdisciplinary team (IDT) would evaluate the fall by reviewing the fall incident report to determine a Root Cause Analysis (RCA) of the fall and further interventions may be put into place according to the determined cause of the fall, to help prevent further falls.
Any further interventions that were developed would be documented.
The immediate jeopardy was issued at PNC after it was verified the facility implemented the following prior to survey: -R1 was sent to ER for evaluation following fall on 9/12/25, and will be reassessed on return from the hospital for proper sling size and care plan updated. -Sling and lift used for R1's transfer was removed from use until inspected and found to be free of malfunction. -NA-A and NA-B had return demonstration competency testing done on 9/12/25, for safe lifting using the mechanical lift. -The facility reviewed their policy and procedure for safe mechanical lift transfers and developed a plan to ensure identification via color coding the sling loops to ensure the correct one being used.
Policy will be adjusted after mechanical lift representative reviews policy on 9/23/25, if needed. -All residents utilizing similar slings like R1 have had the proper sling to use marked with the colored tape to identify the same loops.-All residents who utilized the mechanical lifts had slings inspected, care plans reviewed to ensure the proper sling size in the care plan. -The facility began re-education with return demonstration, to nursing staff on manufacturer's recommendations of using the full body mechanical lift to include checking the straps for tension and using proper sling size according to the care plan beginning on 9/12/25, and will be having mechanical lift representative provide education on 9/23/25, to all of the nursing staff.
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