McIntosh Senior Living: Resident Fracture from Wrong Lifts - MN
The incident at McIntosh Senior Living involved several nursing assistants and even the facility beautician, all of whom knew the resident's care plan specifically directed them to use a mechanical stand for transfers.
Nursing Assistant B admitted during an August 19 interview that she had performed pivot transfers with the resident multiple times, despite knowing it wasn't the first time she had done so. The resident's care plan clearly indicated staff were supposed to transfer using a mechanical stand.
Another nursing assistant, NA-C, told inspectors that staff "including herself, had been performing pivot transfers for R1 but not all the time." She said she wasn't sure why they were doing pivot transfers but acknowledged "they should not have." NA-C confirmed the resident's care plan directed staff to use a mechanical stand.
The beautician became involved when the resident needed to move from her wheelchair to the salon chair. Beautician A said Nursing Assistant D came into the salon and attempted to transfer the resident by herself but "was not strong enough." The beautician then assisted with a pivot transfer to get the resident into the chair.
After finishing the resident's hair, no staff were available. So the beautician took matters into her own hands.
"She placed her arms around R1, like a bear hug, under her arms and transferred her back into her wheelchair," according to the inspection report. The beautician said she thought it was acceptable to help with just one person since she had seen NA-D attempt the transfer alone.
The resident then tried to propel herself to the dining room in her wheelchair, but another staff member brought her back to use the bathroom before helping her to the dining room.
The Director of Nursing told inspectors that once they discovered staff weren't following the transfer requirements, they immediately educated the nursing assistants and beautician. The facility also started audits of transfers and specifically told the beautician she was not allowed to perform any resident transfers.
The physician's assessment was stark. The doctor said the resident had severe osteoporosis and believed the pivot transfers, combined with her diagnosis, contributed to the fracture.
The facility's own policies made the violations clear. Their Safe Patient Handling Program, dated March 19, 2023, stated it was facility policy that when residents required assistance to move, "that assistance was provided in a manner safe for the residents" using "mechanical lifting equipment and/or other patient moving aides."
A separate policy on providing care as outlined in resident care plans, dated April 11, 2023, was even more direct: "All employees must follow each resident's plan of care exactly as written. Care must be delivered by the interventions, safety precautions, and restrictions listed in the plan of care."
The facility had started taking action before the inspection even began. On August 12, a week before inspectors arrived, management had initiated disciplinary action and education about following care plans. They also started compliance audits to ensure staff were following care plans.
But the damage was already done. Multiple staff members had repeatedly ignored explicit safety requirements for a resident with a condition that made her bones extremely fragile. Their shortcuts led to exactly the kind of injury the care plan was designed to prevent.
The beautician's involvement highlighted how the facility's safety failures extended beyond nursing staff. Someone with no medical training was left to perform transfers that even trained nursing assistants found challenging, using techniques specifically prohibited for this vulnerable resident.
The resident's severe osteoporosis made proper transfer techniques critical. Pivot transfers require residents to bear weight and twist their bodies in ways that can stress fragile bones. Mechanical lifts eliminate this risk by supporting the resident's full weight during movement.
Federal inspectors found the facility had caused actual harm to the resident through these repeated care plan violations. The fracture represented a preventable injury that occurred because multiple staff members chose convenience over safety protocols designed to protect a medically fragile resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mcintosh Senior Living from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
McIntosh Senior Living in MCINTOSH, MN was cited for violations during a health inspection on August 19, 2025.
The resident's care plan clearly indicated staff were supposed to transfer using a mechanical stand.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.