Central Todd County Care Center

In the surveyor’s words

From the most serious findings on record at Central Todd County Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 29, 2025

  Based on observation, interview and document review, the facility failed to implement standards of practice to ensure a safe transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to use a transfer belt. This resulted in actual harm when R1 fell during a staff assisted transfer, sustained a fractured and dislocated left arm, multiple rib fractures and was sent to the emergency department (ED) requiring medical treatment and kept overnight for observation and pain control. Findings include: R1's quarterly Minimum Data Set, dated [DATE], identified she was admitted to the facility on [DATE], from home/community. R1 had severe cognitive impairment with disorganized thinking, without behaviors and required substantial/maximal assistance with all transfers. […]

• No harm, potential for more than minimal, patternF610Oct 29, 2025

  Based on observation, interview and document review, the facility failed to conduct a comprehensive, complete investigation,, including a root cause analysis (RCA) and provide sufficient protection to other residents while the investigation was completed for 1 of 3 residents (R1) who was reviewed for accidents. This had the potential to affect all 19 residents who required staff assistance with a gait belt to transfer.Findings include: R1's quarterly Minimum Data Set, dated [DATE], identified she was admitted to the facility on [DATE], from home/community. She had severely impaired cognition with disorganized thinking, without behaviors. She required substantial/maximal assistance with all transfers. […]

• No harm, potential for more than minimal, patternF812Aug 5, 2021

  Based on observation, interview, and document review, the facility failed to ensure expired and/or outdated food products, including both dry stock and refrigerated items, were removed from rotation and not available for resident use or consumption which could cause potential foodborne illness. This had potential to affect 30 of 43 residents identified who could receive these items. Findings include: On [DATE], at 9:35 a.m. the main production kitchen was toured. A dry storage area was located adjacent to the kitchen which contained metallic shelving and various items available to resident food use or preparation. […]

• No harm, potential for more than minimal, isolatedF558Mar 18, 2026

  Based on observation, interview, and document review, the facility failed to ensure a resident's call light was accessible for 1 of 1 residents (R15) reviewed for call light accessibility. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had severely impaired cognition and had a diagnosis that included Alzheimer's disease (disease that cause dementia), non-Alzheimer's dementia. R15 needed maximal assistance with toileting and touching assistance with transfers. R15's care plan revised on 1/15/26, identified R15 was at risk for falls, and staff were to reinforce the need to call for assistance. R15's fall safety assessment dated [DATE], identified R15 of having a moderate risk for falls. […]

• No harm, potential for more than minimal, isolatedF880Mar 18, 2026

  Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with Centers for Disease Control (CDC) guidelines for 1 of 2 (R19) residents who were reviewed for enhanced barrier precautions. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central… […]