Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Central Todd County Care Center during CMS and state inspections, most recent first.
Call Light Not Kept Within Reach: A resident with severely impaired cognition, Alzheimer's disease, and non-Alzheimer's dementia had a call light placed out of reach while lying in bed. The resident needed maximal assistance with toileting and touching assistance with transfers, and the care plan directed staff to reinforce calling for assistance. NAs confirmed the call light should have been within reach, and the DON stated staff were expected to keep it in reach at all times.
A resident with severe cognitive impairment, Parkinson's disease, dementia, dependence for ADLs, and an open pressure ulcer was not placed on EBP during wound care. Staff entered the room without EBP signage or gowns, and the RN performed dressing change and wound care using gloves only. The RN initially stated the wound was not chronic, but the RNCC, DON, and IP all verified the resident should have been on EBP for the wound.
A resident with severe cognitive impairment and multiple physical limitations was transferred by staff without the use of a gait belt, contrary to care plan and facility policy. During the transfer, the resident tripped and was lowered to the floor, resulting in a fractured and dislocated arm and multiple rib fractures. Staff interviews and observations revealed inconsistent use of gait belts and improper transfer techniques, contributing to the resident's injuries.
A resident with severe cognitive impairment and multiple physical conditions was injured during a staff-assisted transfer when a gait belt was not used as required. The staff member involved used improper technique and admitted to not following proper procedures. The facility did not complete a thorough investigation or root cause analysis, failed to interview other potentially affected residents, and did not remove the staff member from resident care duties during the investigation, contrary to facility policy.
A resident with severe cognitive impairment and multiple fractures was re-admitted from the hospital after a fall, but the facility failed to complete a fall risk or therapy assessment upon return. Staff inconsistently used gait belts and sometimes relied on the resident's clothing during transfers, contrary to policy and safe practice. Facility documentation and staff interviews confirmed that required reassessments and updated interventions were not completed, leaving the resident at continued risk for falls and injury.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a resident's call light was accessible for 1 of 1 residents reviewed for call light accessibility. The resident had severely impaired cognition and diagnoses including Alzheimer's disease and non-Alzheimer's dementia, and needed maximal assistance with toileting and touching assistance with transfers. The resident's care plan identified the resident as at risk for falls and directed staff to reinforce the need to call for assistance, and the fall safety assessment identified a moderate fall risk. During observation, the resident was lying in bed and the call light was not accessible; it was clipped to the call light wire coming out of the wall, positioned approximately two feet above the bed and a foot away from the end of the bed above a small dresser. Nursing assistants later verified the resident should have access to the call light when in the room and moved it into reach. The DON stated the resident's fall interventions were appropriate and that staff were expected to follow the care plan and ensure the call light was in reach at all times.
Failure to Use Enhanced Barrier Precautions for Resident With Open Pressure Ulcer
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with CDC guidance for one resident with an open pressure ulcer. The resident had severely impaired cognition, Parkinson's disease, non-Alzheimer's dementia, dependence on staff for dressing, toileting, and transfers, and a pressure ulcer that was present on entry and received ongoing wound care. The resident's care plan identified alteration in skin integrity related to a pressure injury on the left buttocks, but the care plan lacked EBP. During observation on 3/17/26, there were no signs on the resident's door indicating EBP and no gowns available for staff to use. Nursing assistant staff and an RN entered the room, assisted the resident into a mechanical standing lift, and the RN performed wound care. The RN applied gloves, removed the old dressing, noted drainage, cleansed the wound, removed gloves, sanitized hands, reapplied gloves, measured the wound, applied skin prep around the wound, and placed a new dressing. The RN stated the resident was not on EBP because the wound was not chronic, explaining that it had healed in the past and had been open for about two weeks. Further interview and record review showed the resident had an open wound documented on the altered skin integrity sheet and had dressing changes ordered in the EMAR. The RN care coordinator verified the resident had a chronic wound and should have been placed on EBP. The DON also verified the resident should have been on EBP related to having a wound, and the infection preventionist confirmed the resident should have been on enhanced barrier precautions for an open wound. Facility policy stated EBP would be used for residents with chronic wounds, including pressure ulcers, and required gown and glove use during high-contact care activities such as dressing changes and wound care.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to implement standards of practice to ensure a safe transfer for a resident with severe cognitive impairment and multiple physical limitations. The resident, who had diagnoses including Alzheimer's disease, morbid obesity, multiple fractures, and severe cognitive impairment, required substantial to maximal assistance with all transfers and was identified as high risk for falls. Despite care plan and facility policy expectations for the use of a gait belt during transfers, staff assisted the resident in a transfer without applying a gait belt, instead using the resident's clothing for support. During the transfer, the resident tripped and was lowered to the floor by the nursing assistant, resulting in actual harm. The resident sustained a fractured and dislocated left arm, multiple rib fractures, and required emergency department evaluation, medical treatment, and overnight observation for pain control. Documentation and interviews confirmed that the gait belt was not used during the transfer, and staff had a pattern of not consistently using gait belts, sometimes relying on residents' clothing for support. The resident's cognitive status was such that she could not make informed decisions regarding refusal of safety devices, and staff were expected to use a gait belt regardless of any prior refusals. Observations and interviews revealed that staff were not consistently trained or audited on the correct use of gait belts, and there was confusion regarding proper transfer techniques, including where staff should position themselves during transfers. The facility's own policies required assessment and use of appropriate safety devices, including gait belts, for residents at risk of falls. The failure to use a gait belt as required directly led to the resident's fall and subsequent injuries.
Failure to Conduct Comprehensive Investigation and Ensure Resident Protection After Transfer Injury
Penalty
Summary
The facility failed to conduct a comprehensive and complete investigation, including a root cause analysis, following an incident in which a resident experienced an unsuccessful staff-assisted transfer that resulted in significant injuries. The resident, who had severe cognitive impairment, multiple fractures, and required substantial assistance with transfers, was being transferred by a nursing assistant without the use of a gait belt, contrary to facility expectations and the resident's care plan. During the transfer, the resident tripped and was lowered to the floor by the staff member, resulting in a dislocated and fractured left shoulder and multiple rib fractures. The staff member admitted to not using a gait belt and instead used the resident's clothing to assist with the transfer, a practice she stated was easier due to the resident's size and her own habit, despite having received prior training on proper gait belt use during her certification. The investigation into the incident was incomplete. The facility did not conduct a root cause analysis at the time of the event, and the investigation was limited to interviews with the involved staff member and the resident. No other residents who may have received care from the same staff member were interviewed, and the investigation summary was inconclusive due to insufficient information. The staff member involved was not immediately removed from resident care duties during the investigation and continued to work scheduled shifts, despite the facility's policy requiring reassignment or suspension of employees accused of participating in alleged abuse or neglect during an investigation. Observations following the incident revealed inconsistent and improper use of gait belts by staff during resident transfers. Staff interviews indicated confusion regarding proper transfer techniques, including where to stand during transfers and how to use gait belts correctly. The facility's education and audits following the incident focused on the application of gait belts but did not initially address staff positioning or comprehensive safe transfer practices. The lack of a thorough investigation and failure to provide sufficient protection to other residents during the investigation period constituted the deficiency.
Failure to Reassess and Implement Fall Prevention Interventions After Hospital Readmission
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively reassess and implement interventions to reduce the risk of further falls and injury for a resident who was re-admitted from the hospital after sustaining injuries from a fall. The resident had a complex medical history, including Alzheimer's disease, multiple fractures, morbid obesity, and severe cognitive impairment. Upon return from the hospital, there was no evidence in the medical record of a fall assessment or therapy assessment being completed, despite the resident's recent injuries and high risk for falls. The care plan and progress notes did not reflect updated assessments or interventions tailored to the resident's changed condition following hospitalization. Observations and interviews revealed inconsistent and improper use of gait belts during transfers, with staff sometimes relying on the resident's clothing instead of the gait belt, and not always following proper transfer techniques. Staff interviews indicated a lack of understanding and training regarding the correct use of gait belts and the need for reassessment after a significant change in the resident's condition. Family members also reported witnessing unsafe transfer practices, such as staff transferring the resident without a gait belt and using her clothing for support, which raised concerns about the resident's safety. Facility policies required reassessment and determination of the safest transfer method after any change in condition or transfer-related incident, but these procedures were not followed after the resident's return from the hospital. The lack of timely reassessment and failure to update interventions based on the resident's current needs contributed to the ongoing risk of falls and injury. Documentation and staff interviews confirmed that required assessments and communication with therapy were not completed as expected.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clarissa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Long Prairie | 8.4 mi | ★★★★★ | 1 | 0 |
| Lakewood Health System | 19.8 mi | ★★★★★ | 3 | 0 |
| Galeon | 20.8 mi | ★★★★★ | 7 | 0 |
| St Williams Living Center | 22.3 mi | ★★★★★ | 5 | 0 |
| Cura Of Sauk Centre | 24.4 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.