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 12:30 p.m., NA-C stated staff, including herself, had been performing pivot transfers for R1 but not all the time. NA-C said she was not sure why but said they should not have. NA-C said R1's care plan directed staff to use a mechanical stand for transfers.
During interview on 8/19/25, at 12:42 p.m., the facility beautician (B)-A stated R1 needed to get from her wheelchair to the salon chair and said NA-D came into the salon and attempted to transfer R1 by herself but said she was not strong enough. B-A stated she assisted NA-D to pivot transfer R1 to the chair. B-A said after she was finished with R1's hair, no 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.
Facility ID: