Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Three Links Care Center during CMS and state inspections, most recent first.
A resident with significant mobility and medical needs fell from a full body mechanical lift during a transfer when two nursing assistants failed to properly attach the sling, using different length loops on each side. This error caused the sling to detach, resulting in the resident sustaining a new femur fracture that required hospitalization and surgery.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not uphold the resident's right to make decisions about their care or daily activities.
A resident with a recurring pressure ulcer on the right foot was incorrectly coded on the MDS as having a stage two ulcer, despite prior documentation and provider assessment indicating a stage three ulcer in the same location. The MDS coordinator did not identify the previous stage three diagnosis due to incomplete documentation, resulting in inaccurate assessment coding.
Care and assistance were not provided to a resident who was unable to perform activities of daily living independently, resulting in unmet needs for essential daily support.
A resident with a feeding tube, who required enhanced barrier precautions due to infection risk, did not receive proper infection control measures when a registered nurse administered medications and tube feeding without wearing a gown as required. Despite clear facility policy, signage, and staff training on EBP, the nurse only wore gloves, and this lapse was acknowledged during interviews with staff and the infection control nurse.
A resident with COPD and receiving hospice care was not properly re-assessed for safe self-administration of nebulizer medication. Despite being observed falling asleep during treatments, the facility did not ensure consistent supervision or re-evaluation of the resident's ability to self-administer. Nursing staff were aware of the issue but did not inform the nurse manager, leading to a deficiency in following the facility's policy for periodic re-assessment.
A resident's preference for twice-weekly baths was not honored, impacting her quality of life. Despite her care plan indicating a need for two baths weekly due to mobility issues, the schedule was reduced to once weekly without explanation or consent. Nursing staff were unaware of the change, and facility records lacked justification for the alteration.
The facility failed to manage trust account balances for two residents, resulting in amounts exceeding the SSI threshold, risking Medicaid coverage. The accountant was unaware of asset limits and necessary actions, and the administrator did not follow up on the issue. No communication with residents or families about spending down funds was evident.
A resident with osteoarthritis and a pressure injury experienced unmanaged pain due to the facility's failure to develop a comprehensive care plan. Despite assessments indicating the need for pain management, the care plan lacked problem statements, goals, or interventions. Nursing staff confirmed the resident's complaints of pain, but the care plan was not updated to reflect these needs, contrary to the facility's policy.
A facility failed to assess and provide appropriate ROM care for a resident with severe cognitive impairment and a contracture of the left hand after a significant change in condition. Despite being discharged from hospice, the resident was not reassessed for therapy, and the facility's staff missed a request for a therapy screen. Observations showed the resident was awake and engaged, contradicting claims that they were not suitable for exercises. The facility's policy for evaluating residents for restorative services was not followed.
A resident with loose-fitting dentures did not receive timely dental care from the facility, leading to complications such as trouble eating and discomfort. Despite being identified as edentulous with broken or loose-fitting dentures upon admission, the facility failed to offer or provide dental services. Interviews with staff revealed that the resident had declined a specific dental service, but no follow-up or documentation of alternative dental care options was provided, resulting in a deficiency.
A resident with a history of UTIs and an indwelling urinary catheter did not receive proper infection control during personal hygiene and catheter care. A nursing assistant used the same washcloth for multiple areas, including the catheter, without changing gloves or performing hand hygiene. The facility's policy required standard precautions and competency in catheter care, which were not followed.
The facility failed to provide quarterly trust account statements to residents, as required by policy. A resident with intact cognition reported never receiving a statement for their trust account, which was managed by the care center. The accountant responsible admitted that no statements had been mailed out in 2024 due to a recent change in management and banking institutions. The administrator was also unaware of when the last statements had been sent, leading to the deficiency.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure safe transfers for a resident using a full body mechanical lift. Two nursing assistants were involved in transferring a resident who was dependent on staff for all transfers and had significant medical conditions, including a recent femur fracture, artificial hip joint, hemiplegia, and hemiparesis. During the transfer, the nursing assistants did not follow the manufacturer's recommendations for the lift and did not properly attach the sling, specifically using different length black loops on each side of the sling, which caused slack and led to the sling detaching from the lift arm. The resident slipped out of the improperly secured sling and fell from an elevated height, striking his head on the ground. The incident resulted in a new fracture of the right femur, requiring hospitalization and surgical intervention. Documentation and interviews confirmed that the nursing assistants were aware that the same length loops should be used but failed to ensure this during the transfer. Additionally, they had not received specific training on the type of sling used for this resident, which had two sets of black loops that could be easily confused. The facility's policies required staff to use appropriate techniques and processes when utilizing mechanical lifts and to conduct root cause analyses following falls. However, the staff involved did not adhere to these protocols, and the lack of specific training on the sling contributed to the incident. The root cause was identified as the use of different length loops, which led to the release of tension and the resident's fall.
Removal Plan
- R1 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 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, 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 and will be having mechanical lift representative provide education to all of the nursing staff.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support residents in making their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Inaccurate MDS Coding for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for one resident, resulting in the potential for inaccurate federal reimbursement and resident care planning. Specifically, a resident with a history of a stage three pressure ulcer on her right foot between her toes was incorrectly coded as having only a stage two pressure ulcer on the quarterly MDS assessment. Documentation and provider notes indicated that the wound had previously been assessed as a stage three ulcer and had recurred in the same location, but the MDS coordinator was unaware of the prior stage three diagnosis due to the absence of this information in the diagnosis list. As a result, the wound was not coded at its worst stage as required by the CMS Long-Term Care Facility Resident Assessment Instrument User's Manual. Interviews with nursing staff and the MDS coordinator confirmed that the wound was open and unhealed at the time of the assessment, and that the coding error occurred because the prior stage three ulcer was not documented in the diagnosis list. The facility's policy required all interdisciplinary team members to review the current RAI manual and for the MDS coordinator to conduct audits to identify and correct errors, but this process was not followed, leading to the inaccurate MDS coding for the resident.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified in the facility's provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform essential daily activities.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding Care
Penalty
Summary
A deficiency occurred when staff failed to follow enhanced barrier precautions (EBP) for a resident with a feeding tube. The resident, who was cognitively intact and had diagnoses including dysphagia following cerebral infarction, pharyngeal dysphagia, diverticulum of esophagus, gastrostomy, anxiety, and gastroesophageal reflux, was on enteral feeding and had specific orders and care plan instructions for EBP. Facility policy and signage on the resident's door required staff to wear gloves and a gown during high-contact care activities, including tube feeding management. During an observed medication and feeding administration, a registered nurse washed her hands and donned gloves but did not wear a gown as required by EBP. The nurse acknowledged forgetting to wear the gown and confirmed the resident was on EBP due to the feeding tube and infection risk. Interviews with other staff and the assistant director of nursing/infection control nurse confirmed the expectation to use gloves and gowns for such care, in line with facility policy and recent staff training. The failure to wear a gown during high-contact care for a resident with an indwelling medical device constituted a breach of the facility's infection prevention and control program.
Failure to Re-assess Safe Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to comprehensively re-assess a resident's ability to safely self-administer medication via a nebulizer. The resident, who had intact cognition and was diagnosed with respiratory failure and COPD, was receiving hospice services and had been observed falling asleep during nebulizer treatments. Despite this, the resident's assessments indicated they were able to demonstrate correct administration of medication after staff set-up. However, due to reports of the resident falling asleep during administration, it was determined that the resident was not administering the medication safely, and a nurse was required to observe the treatments. Observations and interviews revealed that the resident frequently fell asleep during nebulizer treatments, causing the nebulizer to fall out of their mouth and their oxygen saturation to lower. The nursing staff, including the LPN and RN, were aware of this issue but did not consistently stay with the resident during treatments due to the high frequency and time required for each session. The nurse manager, responsible for assessing the safety of self-administration, was not informed of the resident's tendency to fall asleep during treatments. The facility's policy required periodic re-assessment of the resident's ability to self-administer medications, but this was not adequately followed, leading to the deficiency.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's preference for bathing routines, which impacted the resident's quality of life and choice. The resident, identified as R7, expressed frustration during an interview about a reduction in her bathing schedule from twice weekly to once weekly without any explanation. R7's care plan indicated she required extensive assistance with activities of daily living due to weakness and mobility issues, and her bathing routine was initially set for twice a week. However, the care plan was updated to reflect a weekly bath without documented consent or rationale for this change. Interviews with nursing staff revealed that the reduction in R7's bathing schedule was not formally communicated or justified. RN-A confirmed that R7 was supposed to receive two baths weekly, which was also an intervention for her skin issues. The facility's bath schedule and records corroborated the change to a weekly bath, but lacked any evidence of consent or justification for the alteration. The facility's policy on person-centered care planning emphasized the development of care plans consistent with residents' rights and needs, yet no specific policy on choices and bathing preferences was provided upon request.
Failure to Manage Resident Trust Account Balances
Penalty
Summary
The facility failed to manage resident trust account balances exceeding the state-required Supplemental Security Income (SSI) threshold, which is $3,000 for individuals. Two residents, identified as R13 and R42, had trust account balances of $14,648.82 and $12,740.57, respectively, which were not addressed to ensure continued Medicaid coverage. The facility did not take action to reduce these balances, known as a 'spend down,' to prevent potential termination of Medicaid benefits due to exceeding asset limits. Interviews and document reviews revealed that the accountant responsible for managing resident accounts was unaware of the specific asset limits under Minnesota Medicaid law and had not been informed about the necessary actions to address the excess balances. The accountant acknowledged the oversight and mentioned that the transition to a new management company and banking institution might have contributed to the confusion. Additionally, the administrator had not followed up on the issue, and there was no evidence of communication with the residents or their families regarding the need to spend down the funds.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R7) who was assessed for pain management. R7's quarterly Minimum Data Set (MDS) indicated that the resident had intact cognition, consumed scheduled pain medication, and received non-pharmacological interventions for pain. Despite these assessments, R7's electronic care plan lacked any problem statements, goals, or interventions related to the resident's pain management. Interviews with R7 revealed that they experienced pain in their left leg from a fall and were unsure if the physician or staff were aware of it. The resident's pain assessment identified osteoarthritis and an active pressure injury as potential pain sources, with pain affecting sleep and activities. Interviews with nursing staff confirmed that R7 occasionally complained of pain, particularly during transfers using a mechanical lift. Nursing assistants relied on verbal reports and electronic kardex for communication about interventions. However, the registered nurse managers acknowledged that R7's care plan did not include a pain statement or interventions, which should have been addressed. The facility's Person Centered Care Planning policy required a comprehensive care plan to be developed within seven days of the MDS completion, but this was not adhered to in R7's case.
Failure to Assess and Provide ROM Care for Resident
Penalty
Summary
The facility failed to comprehensively assess and provide appropriate care for a resident, identified as R31, to maintain or improve range of motion (ROM) after a significant change in condition. R31, who has severe cognitive impairment, unspecified dementia, traumatic brain injury, and a contracture of the left hand, was dependent on staff for all activities of daily living (ADLs). Despite being discharged from hospice due to a prognosis of greater than six months, the facility did not reassess R31 for ROM exercises or therapy. Observations showed R31 was awake and engaged during family visits, contradicting the therapy staff's claim that R31 was not appropriate for exercises due to sleeping all the time. The facility's staff, including the therapy director and nurse manager, acknowledged that R31 had not been evaluated for therapy since December 2023, and a request for a therapy screen was missed after R31's discharge from hospice. The facility's policy requires residents to be evaluated for restorative nursing services at least quarterly and with changes in condition, but this was not adhered to in R31's case. The staff task list and nursing assistant Kardex lacked documentation of ROM exercises, indicating a failure to implement a functional maintenance program for R31, despite the family's expressed desire for R31 to participate in ROM exercises.
Failure to Provide Timely Dental Care for Resident with Loose Dentures
Penalty
Summary
The facility failed to provide timely dental services to a resident, identified as R39, who had loose-fitting dentures. R39 was admitted to the care center from an acute care hospital and was noted to have intact cognition and no delusional thinking. Upon admission, R39 was identified as edentulous with broken or loose-fitting dentures. Despite this, the facility did not offer or provide timely dental care to address the issue, which led to complications such as trouble eating and discomfort for the resident. R39 expressed concerns about her loose-fitting dentures during an interview, stating that she was not wearing them due to their poor fit and that it really bothered her. The facility's documentation, including the Ancillary Services Consent and Oral Dental Review, lacked evidence of any dental options being discussed or offered to R39. The resident's care conference summary also failed to address the need for a dental examination, despite the identification of loose-fitting dentures during evaluations on multiple occasions. Interviews with facility staff, including nursing assistants and registered nurse managers, revealed that R39 had declined the Apple Tree Dental service upon admission. However, there was no follow-up or documentation of any dental appointment being discussed or offered after the loose dentures were identified. The facility's Dental Services policy stated that they would provide or obtain dental services to meet residents' needs, but this was not adhered to in R39's case, resulting in a deficiency in providing necessary dental care.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during personal hygiene and urinary catheter care for a resident diagnosed with heart failure, kidney disease, and respiratory failure. The resident, who had intact cognition, was dependent on staff for toileting hygiene, bed mobility, and transfers, and had a history of urinary tract infections related to an obstruction of the urinary tract. The care plan required assistance with catheter care every morning and night, and the resident had an indwelling urinary catheter with output to be assessed every shift. During an observation, a nursing assistant was seen using the same washcloth for multiple areas of the resident's body, including the catheter area, without changing gloves or performing hand hygiene between tasks. The nursing assistant admitted to using one washcloth for all resident care, including catheter care, and acknowledged not performing hand hygiene or changing gloves between tasks. The director of nursing stated that the nursing assistant should have changed gloves and completed hand hygiene before and after catheter and perineal care. The facility's policy on urinary catheter care and management emphasized maintaining resident safety by following infection control practices, including using standard precautions and demonstrating competency in catheter care. However, these practices were not followed, leading to concerns about the potential for infection.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly trust account statements to residents, as required by their policy. This deficiency was identified during a recertification survey when a resident, who had intact cognition, reported never receiving a statement for their trust account, which was managed by the care center. The resident confirmed having a small balance in the account but had not been informed of the exact amount through a statement. The facility's records showed that 27 residents, including this resident, had active trust accounts, but no evidence of statements being provided was available. The accountant responsible for managing the residents' accounts admitted that no statements had been mailed out in 2024, citing a recent change in management and banking institutions as reasons for the oversight. The administrator, who was new to the facility, was also unaware of when the last statements had been sent. The facility's policy, dated April 2020, required that statements be sent quarterly to residents or their authorized representatives, but this had not been adhered to, leading to the deficiency.
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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 Northfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Emeralds At Faribault Llc | 12.4 mi | ★★★★★ | 3 | 0 |
| Trinity Care Center | 12.8 mi | ★★★★★ | 6 | 0 |
| Apple Valley Village Health Care Center | 19.4 mi | ★★★★★ | 1 | 0 |
| Mala Strana Care & Rehabilitation Center | 20.9 mi | ★★★★★ | 2 | 0 |
| Ebenezer Ridges Geriatric Care Center | 21.1 mi | ★★★★★ | 4 | 0 |
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