Mcintosh Senior Living
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
was not the first time she had performed a pivot transfer with Resident R1. NA-B said Resident R1's care plan indicated staff were to transfer using a mechanical stand. During interview on 8/19/25 at 12:30 p.m., NA-C stated staff, including herself, had been performing pivot transfers for Resident R1 but not all the time. NA-C said she was not sure why but said they should not have. NA-C said Resident 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 Resident R1 needed to get from her wheelchair to the salon chair and said NA-D came into the salon and attempted to transfer Resident R1 by herself but said she was not strong enough. B-A stated she assisted NA-D to pivot transfer Resident R1 to the chair. B-A said after she was finished with Resident R1's hair, no staff were around so she placed her arms around Resident R1, like a bear hug, under her arms and transferred her back into her wheelchair. B-A said after she got into
the wheelchair Resident R1 started to propel herself to the dining room but said another staff brought Resident 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 Resident 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 Resident 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 Resident 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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McIntosh Senior Living in MCINTOSH, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MCINTOSH, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from McIntosh Senior Living or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.