Three Links Care Center

In the surveyor’s words

From the most serious findings on record at Three Links Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 19, 2025

  Based on interview and document review the facility failed to ensure safe transfers with a full body mechanical lift for 1 of 3 residents (R1) reviewed for falls/safety. The facility's failure resulted in an immediate jeopardy situation for R1 when he slipped out the full body mechanical lift sling and fell from an elevated height. R1 was hospitalized due to a new fracture of the right femur and needed surgical intervention. The IJ began on 9/12/25, when 2 of 2 nursing assistants (NA)-A and NA-B did not follow manufacturer's recommendations for a safe lift transfer using the full body mechanical lift and the sling was not attached properly. As a result, R1 fell from the lift and sustained a new fracture of the right femur that needed surgical intervention. […]

• Immediate jeopardy, isolatedF689Oct 13, 2023

  Based on interview and document review, the facility failed to provide adequate assistance as identified by the care plan to prevent accidents when transferring 1 of 3 residents (R1) reviewed for accidents. This failure resulted in R1 sustaining serious injuries requiring hospitalization and surgery. The immediate jeopardy began on 10/2/23 at approximately 1:05 p.m. when while R1 was transferred by nursing assistant (NA)-A with one assist instead of two as directed by the care plan, became weak and fell to the floor. R1 sustained an open fracture of her left ankle which required surgical intervention and an extended stay at a hospital. The administrator and director of nursing (DON) were notified of the IJ on 10/13/23 at 3:15 p.m. […]

• No harm, potential for more than minimal, patternF812Aug 17, 2023

  Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers using the main production kitchen. This had potential to affect all residents who could potentially consume the items. Findings include: On 8/14/23 at 1:42 p.m., an initial kitchen tour was completed with the director of culinary service (DCS) present. A single CrownTonka walk-in commercial freezer was in use, opened, and inspected. […]

• No harm, potential for more than minimal, patternF689May 19, 2022

  Based on observation, interview and document review, the facility failed to ensure the Atrium dining room cleaning chemicals were secured away in a locked cabinet or cart, which had the potential to affect 26 of 50 residents who could access the Atrium dining room. Findings include: On 5/16/22, at 2:15 p.m. during observation of the Atrium dining room, a three-quarter full bottle labeled Ecolab Sink Surface Cleaner, a half full container of Diversity Oxivir Tb, a three-quarter full bottle of Clorox Fusion Cleaner Disinfectant, a half full bottle of 3M neutral cleaner, a half-full bottle of Alpha Hp Bathroom Cleaner, and a three-quarter full bottle of TrueKleen Lime off were in the Atrium dining room unsecured in a lower-level cabinet to the left of the sink. […]

• No harm, potential for more than minimal, patternF689Jul 13, 2021

  Based on interview and document review, the facility failed to ensure routine device monitoring was completed for their wanderguard door systems. This practice had the potential to affect all residents whom had wanderguard devices in place at the time of the onsite visit for 5 of 5 residents (R1, R2, R3, R4, R5). Findings include: R1's face sheet printed 7/13/21, indicated diagnoses of mild cognitive impairment and ataxia (condition where muscle control or coordination of voluntary movements, such as walking or picking up objects is affected) following a cerebral infarction (stroke). R1's care plan dated 5/13/21, indicated R1 could self-propel himself in manual wheelchair without assist. […]