McIntosh Senior Living: Unsafe Transfer Causes Fracture - MN
The resident had severe osteoporosis. She fractured.
Federal inspectors cited the facility for actual harm following a complaint inspection on August 19, 2025. The violation centered on a single resident, identified in inspection records as R1, whose care plan required a mechanical stand for all transfers. Nobody used one.
The nursing assistant, identified as NA-D, came into the salon to move R1 from her wheelchair to the salon chair. The beautician, identified in records as B-A, told inspectors that NA-D attempted the transfer alone but said she wasn't strong enough. So the beautician stepped in, and together they pivot-transferred R1 to the chair. That was already a departure from the care plan. What happened next was worse.
When R1's appointment was finished, no staff were around. The beautician told inspectors she placed her arms around R1 "like a bear hug," under her arms, and transferred her back into the wheelchair by herself. She said she thought it was acceptable to help with one person doing the transfer because NA-D had been willing to try it alone.
R1 propelled herself toward the dining room. Another staff member brought her back to use the bathroom first. At some point in this sequence, she fractured.
The director of nursing told inspectors that after the facility discovered staff had not been following R1's care plan, they educated the nursing assistants and the beautician, began audits of transfers, and made clear that the beautician was not to perform resident transfers. The physician's assessment, relayed through the DON, was that the pivot transfers combined with R1's severe osteoporosis contributed to the fracture.
The facility's own safe patient handling policy, dated March 2019, required that residents needing movement assistance be moved in a manner safe for them, specifically using mechanical lifting equipment or other patient moving aids. Its care plan policy, dated April 2023, stated that all employees must follow each resident's plan of care exactly as written.
Neither policy was followed. The nursing assistant knew R1 needed a mechanical stand and came to the salon without one. The beautician knew, by the end of the appointment, that no staff had returned and made the decision to move R1 herself rather than wait or call for help.
The facility had begun disciplinary action and education before inspectors arrived, on August 12, a week before the survey. Compliance audits were underway. Inspectors verified both through interviews and document review.
None of that changes what R1's care plan required, what staff did instead, or what happened to her bones.
The inspection report does not describe the fracture's location or severity, how long R1's recovery took, or whether she was hospitalized. It does not name her. It records that she started wheeling herself toward the dining room after the transfer, that another staff member redirected her to the bathroom first, and that somewhere in that ordinary sequence of a haircut and lunch, a woman with severe osteoporosis was hurt by people who knew, or should have known, that moving her without a mechanical lift was dangerous.
The beautician told inspectors she thought one person helping was fine because a nursing assistant had been willing to go it alone. That reasoning, passed between two people who were not following the care plan, was the last decision made before R1 fractured.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
MCINTOSH SENIOR LIVING in MCINTOSH, MN was cited for violations during a health inspection on August 19, 2025.
The resident had severe osteoporosis.
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.