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
Review of the facility's
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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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.