Mcintosh Senior Living
MCINTOSH SENIOR LIVING in MCINTOSH, MN — inspection on August 19, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During interview on 8/19/25, at 12:42 p.m., the facility
into the salon and attempted to transfer R1 by herself but said she was not strong enough. B-A stated
staff were around so she placed her arms around R1, like a bear hug, under her arms and transferred her back into her wheelchair. B-A said after she got into the wheelchair R1 started to propel herself to the dining room but said another staff brought R1 back to use the bathroom before assisting her to the dining room. B-A said she thought since NA-D was going to transfer R1 by herself it was okay to assist with just one person.During interview on 8/19/25, at 3:02 p.m., the DON stated after they discovered staff had not been following the care plan for transfers with R1, they had immediately educated the NA's and B-A and initiated education with all staff that provide care and transfer residents.
The DON stated they had also initiated audits of transfers and educated B-A she was not to perform any resident transfers.
The DON said the physician said R1 had severe osteoporosis and felt the pivot transfers along with her diagnosis contributed to the fracture.Facility Policy Safet-patient-handling Program dated 3/19/23, indicated it was the policy of the facility that when residents required assistance to move residents, that assistance was provided in a manner safe for the residents.
Specifically, mechanical lifting equipment and/or other patient moving aides.Facility Policy Providing Cares as Outlined in the Resident Care Plan dated 4/11/23, indicated 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.Prior to the start of the survey, on 8/12/25, the facility had initiated disciplinary action and education related to following the plan of care.
Further, the facility had initiated compliance audits to ensure staff were following the plan of care.
The education and audits were verified through interview and document review.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.