Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Clarkfield Care Center during CMS and state inspections, most recent first.
Failure to document TBP initiation for two residents with respiratory infections. One resident had flu-like symptoms, low O2 sats, and was later diagnosed with influenza A and a UTI, but nursing notes did not state when droplet precautions began. Another resident had pneumonia with cough, reduced O2 sats, and pleuritic chest pain, but the record did not show if or when TBP were started. The infection preventionist stated the date precautions were implemented should be documented in the medical record.
Hospice care plan and service responsibilities were not documented. A resident with severe cognitive impairment, dementia, malnutrition, and major ADL dependence was on hospice services, but staff could not identify a hospice schedule or an integrated care plan showing what hospice would provide and what the facility was responsible for. The hospice RN stated the schedule and care plan should have been provided at admission, but they had not been available at the facility.
A resident with congestive heart failure and hypertension experienced a change in condition, including low oxygen saturation and respiratory distress, but the provider was not notified in a timely manner. The resident was placed on oxygen by an LPN without proper documentation or communication, leading to a delay in appropriate medical intervention.
A facility failed to notify the State Mental Health Authority for a resident with new mental health diagnoses, including unspecified mood disorder and psychosis. Despite the resident's new conditions, the facility did not request a Level II PASARR to evaluate the need for additional services. Staff interviews revealed a lack of awareness about the requirement to contact the local authority for re-evaluation.
A resident with multiple medical conditions sustained a burn injury from a hand warmer, which was not properly documented or investigated by the facility. The burn was reported to a nurse, but no incident report was completed, and the care plan was not updated to prevent further incidents. Despite a provider's order for Bacitracin, the treatment was not documented in the progress notes, and the facility failed to follow its protocol for serious injuries.
A resident with chronic respiratory failure and pneumonia was prescribed oxygen at 2 LPM, but was observed receiving 2.5 LPM. An LPN confirmed the discrepancy and adjusted the flow rate. Facility policy requires adherence to physician orders, which was not followed in this instance.
A resident with a yeast infection did not receive prescribed Monistat cream for two weeks due to a lack of coordination between the facility, pharmacy, and provider. The facility ran out of the medication and failed to obtain a new prescription, leaving the resident in discomfort. Staff interviews revealed communication issues and the absence of a policy for handling unavailable medication supplies.
The facility failed to ensure that data submitted to the QAPI committee was properly analyzed and documented. The QIIP tool aimed to monitor pain in residents during their first 100 days, but lacked thorough data analysis. Interviews revealed that while the tool was in place, there was no additional documentation to support its effectiveness, and the facility did not have a process for executing the QIIP tool effectively.
The facility failed to provide mandatory training on its QAPI Program to all staff, leading to a lack of awareness about QAPI goals, meetings, and staff roles. Interviews with various staff members revealed that they were unaware of specific goals or what the facility was monitoring overall, despite some having completed general online training. The deficiency affected all 24 residents in the facility.
Failure to Document Transmission-Based Precautions
Penalty
Summary
The facility failed to document the date transmission-based precautions (TBP) were implemented for 2 residents with infections. One resident had a confirmed upper respiratory infection identified on 1/30/26 and was placed on droplet precautions from 1/31/26 through 2/6/26. Nursing progress notes documented respiratory assessments showing a non-productive cough, wheezing, fever, oxygen saturation of 90%, tachycardia, and later increased congestion, respirations of 30, and decreased urine output, followed by transfer to the hospital where he was diagnosed with influenza A and a urinary tract infection. The progress notes did not state that TBP had been initiated. The second resident had a confirmed respiratory infection, pneumonia, identified on 1/12/26 with symptoms including new or increased cough, reduced oxygen saturations, and pleuritic chest pain, and was treated with cefdinir. Review of the resident surveillance record and medical record did not identify when or if TBP were started. The infection preventionist stated nursing should place residents on TBP when signs and symptoms of infection are identified and that the date precautions were implemented should be documented in the medical record. The facility’s infection prevention and surveillance policies stated residents with infection or communicable disease shall be placed on TBP per CDC guidelines and that staff are to report changes in condition, including when a resident is placed on isolation precautions.
Hospice care plan and service responsibilities were not documented
Penalty
Summary
The facility failed to ensure hospice services were arranged and documented in a care plan for one resident who was on hospice services. The resident had severe cognitive impairment, was readmitted after an acute care hospitalization, and had diagnoses including hypertension, dementia, malnutrition, anxiety disorder, depression, and macular degeneration with legal blindness. He required maximal assistance with ADLs and used a wheelchair for mobility. Progress notes documented that he was admitted to hospice with a terminal diagnosis of senile degeneration of the brain. During interviews, staff were unable to identify a hospice schedule or a care plan that described what hospice services would provide and what the facility was responsible for. A TMA stated she was not aware of a hospice schedule or care plan and thought information might be at the nursing station. An LPN stated hospice visits had decreased because the resident had improved, but there was no schedule to identify visits and the facility care plan only noted that he was on hospice without identifying hospice services or facility responsibilities. The hospice RN stated a schedule and integrated care plan should have been developed and provided to the facility at admission, but that had not occurred, and the agreement for services and equipment should have been in a binder at the nursing station, but none was available.
Failure to Notify Provider of Change in Condition
Penalty
Summary
The facility failed to notify the provider of a change in condition in a timely manner for a resident who was reviewed for hospitalization. The resident, identified with diagnoses of congestive heart failure and hypertension, was cognitively intact and required substantial assistance with activities of daily living. The resident's medication administration record did not indicate the use of oxygen, although standing orders were in place for oxygen administration under specific conditions. On February 13, the resident complained of fatigue and coldness in the lower extremities, with vital signs showing instability over the previous days. Despite being encouraged to visit the emergency room, the resident refused. The following day, the resident was unable to stand and exhibited symptoms of dizziness and light-headedness, with significantly low blood pressure and oxygen saturation levels. The resident was sent to the emergency room and diagnosed with a bladder infection before returning to the facility. On February 15, the resident was placed on oxygen by an LPN due to shortness of breath, but the provider was not notified of this change in condition. The resident's oxygen saturation levels remained low throughout the day, and the resident was eventually transferred back to the hospital after displaying respiratory distress. Interviews with nursing staff revealed a lack of documentation and communication regarding the resident's condition and the initiation of oxygen therapy, which was not reported to the provider until the resident was sent to the emergency room later that afternoon.
Failure to Notify Mental Health Authority for New Diagnoses
Penalty
Summary
The facility failed to notify the designated State Mental Health Authority (SMHA) for a resident with a new onset of mental illness. The resident, who was admitted in October 2022, had an intact cognition and was diagnosed with several conditions including atrial fibrillation, heart failure, hypertension, renal failure, diabetes, arthritis, dementia, depression, and a psychotic disorder. The resident required substantial assistance with care and was on multiple medications including antipsychotics and antidepressants. New diagnoses were identified, including unspecified mood affective disorder, unspecified psychosis, and restlessness and agitation. Despite these new mental health diagnoses, the facility did not notify the local mental health authority for a Level II Pre-Admission Screening and Resident Review (PASARR) to evaluate the resident for appropriate placement and services. Interviews with facility staff revealed a lack of awareness regarding the requirement to contact the local mental health authority for a resident review following new mental health diagnoses. The registered nurse confirmed that the resident had received a PAS upon admission, which did not indicate the need for a Level II screening. However, the nurse was unaware that new mental health diagnoses necessitated a re-evaluation. The administrator/director of nursing also confirmed the requirement for contacting the local authority but was unaware of the registered nurse's lack of knowledge on this matter. The facility's policy stated that the social service or designee was responsible for coordinating PASARR screenings and referrals, but this was not followed in the case of the resident with new mental health conditions.
Failure to Document and Investigate Resident Burn Injury
Penalty
Summary
The facility failed to properly assess, investigate, and document a burn injury sustained by a resident, identified as R11. R11, who had intact cognition and required substantial assistance with care, was admitted in October 2022 and had multiple medical conditions including atrial fibrillation, heart failure, and diabetes. On December 18, 2024, a burn was identified on R11's upper right chest, but there was no incident report completed, and the burn was not documented in the progress notes. The burn was initially reported by a nursing assistant to RN-A, who assumed the nurse on duty would document it, but this did not occur. The facility's administrator confirmed that an incident report should have been completed, and further skin assessments should have been conducted. The resident revealed that the burn was caused by a hand warmer obtained from another resident, which he used to alleviate muscle pain. Despite the nurse's assessment and the provider's order for Bacitracin, these actions were not documented in the progress notes. The facility's care plan for R11 was not updated to include interventions to prevent further incidents. The facility's protocol required immediate notification and documentation of serious injuries, but these procedures were not followed, leading to a lack of proper documentation and investigation of the incident.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy for a resident diagnosed with chronic respiratory failure and pneumonia. The resident, who was cognitively intact, was prescribed to receive oxygen continuously at 2 liters per minute (LPM) via nasal cannula. However, during an observation, it was noted that the oxygen flow meter was set at 2.5 LPM, exceeding the prescribed amount. This discrepancy was confirmed by a licensed practical nurse (LPN) who subsequently adjusted the flow rate to the correct setting of 2 LPM. The facility's policy on oxygen administration requires staff nurses to follow physician orders and verify oxygen equipment settings to ensure resident safety. Despite these guidelines, the staff failed to maintain the prescribed oxygen flow rate, as evidenced by the observation and subsequent interview with the director of nursing. The director confirmed the expectation for staff to adhere to physician orders regarding oxygen use, highlighting a lapse in compliance with established protocols for oxygen therapy management.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a prescribed medication, Monistat cream, was available and administered to a resident, leading to a deficiency in pharmaceutical services. The resident, who had intact cognition and required assistance with care, was experiencing frequent urinary incontinence and was on a scheduled pain medication, antidepressant, blood thinner, and diuretic. She reported having a yeast infection and was supposed to receive Monistat cream for relief, but did not receive it for two weeks due to a lack of coordination between the facility, pharmacy, and provider. The progress notes indicated that the Monistat cream was not available from 2/28/25 to 3/11/25, despite an order being received on 2/20/25. The pharmacy required a new prescription, which was not obtained, and the facility did not have a policy in place for handling unavailable medication supplies. Interviews with staff revealed that the facility ran out of the medication and failed to effectively communicate with the pharmacy and provider to secure a new supply. The resident continued to experience discomfort, and the issue was not resolved until the provider changed the medication order on 3/11/25.
Failure to Analyze and Document QAPI Data
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance Performance Improvement (QAPI) committee was properly analyzed and documented. This deficiency was identified during a review of the Quality Improvement Incentive Payment (QIIP) tool, which aimed to monitor moderate to severe pain in residents during their first 100 days. The documentation lacked a thorough analysis of the collected data, making it unclear what specific measures needed to be taken. Interviews with the assistant director of nursing and the director of nursing revealed that while the QIIP tool was in place, there was no additional documentation to support its effectiveness, and the facility did not have a process for executing the QIIP tool effectively. The director of nursing, who was also the current facility administrator, acknowledged the need for improvements in the QIIP tool and the overall data collection and analysis process. The executive administrator confirmed that the facility lacked evidence showing the analysis of its current QAPI concerns and did not have a process in place for the execution of the QIIP tool. The facility's QAPI policy stated that they would regularly review and analyze data collected under the QAPI program and act upon that data to make improvements, but this was not being done effectively, affecting all 24 residents in the facility.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program to all staff, affecting the understanding and participation of the program. Interviews with various staff members, including the activity director, nursing assistants, registered nurse, licensed practical nurse, maintenance supervisor, and the director of nursing, revealed a lack of awareness about the QAPI goals, meetings, and the staff's role in the program. Some staff members had completed general online training on QAPI but were unaware of specific goals or what the facility was monitoring overall. The activity director and maintenance supervisor attended QAPI meetings but did not know if other employees could attend or were aware of the specific issues being addressed by the committee. The facility's Quality Assurance/Assessment and Performance Improvement Plan, reviewed on 2/15/24, stated that employees would be trained on using the QAPI process and participate in the performance improvement plan (PIP) team. However, the interviews indicated that this training and involvement were not effectively communicated or implemented. The director of nursing and the executive administrator acknowledged the lack of awareness among staff and stated that QAPI meetings were open to all employees. The deficiency affected all 24 residents in the facility, as the staff's lack of knowledge and participation in the QAPI program could impact the quality of care provided.
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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 Clarkfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luther Haven | 12 mi | ★★★★★ | 2 | 0 |
| Parkview Home | 13.2 mi | ★★★★★ | 8 | 0 |
| Avera Granite Falls Care Center | 14.2 mi | ★★★★★ | 5 | 0 |
| Johnson Memorial Hospital & Home | 15.7 mi | ★★★★★ | 2 | 0 |
| Sylvan Court | 23.7 mi | ★★★★★ | 4 | 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.