McGregor Wellness & Rehabilitation

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the 1-of-1 of kitchen. 1. The facility failed to ensure food items were labeled and/or dated. 2. The facility failed to ensure food items were correctly sealed. 3. The facility failed to ensure food items were properly thawed. 4. The facility failed to ensure food items were not stacked on the floor. 5. The facility failed to ensure food temperatures were taken before serving residents meals. These failures could place residents who received meals from the main kitchen at risk for foodborne illnesses.Findings include: Observation on 3/10/2026 at 8:40 AM of the walk-in cooler revealed the following:A container of white gravy was labeled with a date of 3/9 only with no expiration date.A Ziploc bag of chicken nuggets had no date on the bag.Opened butter wrapped in Saran Wrap had no open date or expiration date.A container of sweet corn was dated only 2/9.A bag of herbs was not sealed and had no opening or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 2 residents (Resident #4) reviewed for accuracy of assessments. The facility failed to ensure Resident #4 was coded in the MDS for pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time). This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment.The findings include: Record review of Resident #4's face sheet, dated 03/12/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with an initial admit date of 05/15/2025. Resident #4's Pertinent diagnoses included: type 2 diabetes mellitus without complications (a person has diabetes, but it has not yet led to any additional health problems or complications), hypokalemia (a medical condition characterized by abnormally low levels of potassium in the blood), hyperlipidemia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure 3 of 3 staff (the KD, CO B and CO C) prepared, distributed and served food in accordance with professional standards for food service safety when reviewed for food procurement, store/prepare/serve-sanitary. The KD, CO B and CO C were observed with exposed mustaches while preparing lunch and handling food. The KD and CO B were observed touching multiple surfaces (food, clothing, books, cellphones) without changing their gloves.Findings included: Observation on 01/06/25 at 11:05 AM revealed the KD, CO A and CO B wearing face coverings that did not cover their mustaches while preparing lunch. Observation also revealed the KD and CO A touching multiple surfaces (clothing, cell phone, books) and preparing lunch while wearing gloves and did not change them. In an interview with the KD on 01/06/26 at 11:05 AM, he stated the policy on hair restraints reflected staff was to have no visible hair exposed. He stated facial hair was also included. The KD stated hair falling in the food was a risk that led to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 5 residents (Residents #1 & #2) reviewed for resident rights. The facility failed to ensure Resident #1 and #2's call lights were within reach on 08/07/2025. This failure could place residents at risk of their needs not being met. Findings include: Record review of Resident #1's admission record, dated 08/07/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: cerebrovascular disease (a condition that affect blood flow to the brain), type 2 diabetes mellitus without complications (a condition where the body either doesn't produce enough insulin or can't properly use the insulin it makes causing blood sugar levels to become too…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for comprehensive care plans Resident #3's comprehensive care plan did not reflect Resident #3 had fallen on 07/12/25 and 07/29/25. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: Record review of Resident #3's admission record, dated 08/07/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: vascular dementia (type of dementia caused by impaired blood flow to the brain, leading to brain cell damage and cognitive decline), depression (mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 4 of 5 Residents (Resident #21, Resident #55, Resident #56, and Resident #58) reviewed for assessments. The facility failed to complete a quarterly assessment for Residents #21, #55, #56, and #58 every 3 months. This failure could place residents at risk for not getting an accurate assessment and could result in lack of care. Findings include: Resident #21 Review of Resident #21's electronic face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses to include: Cerebrovascular disease ( conditions that affect the blood vessels and blood flow in the brain and spinal cord), Hypertension (pressure of the blood in your blood vessels is consistently too high), Anxiety Disorder, Unspecified ( someone who experiences anxiety or phobias that are significant but don't meet the criteria for a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. Some food items that were labeled were out date. These failures could place all residents who received meals from the main kitchen at risk for food borne illness. Findings include: Observation on 12/09/2024 at 7:15 am of the pantry reflected the following: The dried pantry had food that was not dated and some food that was out of date, - Baking soda that had an expiration date of was dated 8-23-24. Observation on 12/9/2024 at 7:25 am of the walk-in cooler reflected the following. - Soup that was dated use by 12-2-2024. - Sauce in a squeeze bottle that was not dated. - Jelly that was dated use by 11-26-2024. - Unknown food with no date. - Cheese that was dated use by 12-4-2024. - Potato soup that was dated use by 12-5-2024 During an interview on 12/09/24 at 7:45 am the KM was made aware of the items…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease for 2 (Residents #1 and Resident #2) of 8 residents reviewed for infection control during medication pass. LVN A failed to remove her gloves and wash her hands before putting on a new set of gloves and after touching the peg tube of Resident #1, and then touching the gtube of Resident #2. These failures placed residents at an increased risk of exposure to infections, decreased quality of life or hospitalizations. Findings include: 1. Review of Resident #1's face sheet, dated 08/24/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] diagnosed with supraventricular tachycardia (erratic heartbeat), anoxic brain damage (occurs when the brain is deprived of oxygen), and personal history of traumatic brain injury. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for dietary services. 1. The facility failed to ensure the DOM and KA A were wearing effective hair restraint, while in food prep areas. 2. The facility failed to ensure air vents were free from dirt and debris. 3. The facility failed to ensure 2 bottles of metal polish, 2 bottles of cleaner, with bleach, and a small bottle of PVC cement were kept separated from the food prep area. 4. The facility failed to ensure the kitchen's only industrial can opener was clean. 5. The facility failed to ensure the facility's only dishwasher was cleaned and de-limed. 6. The facility failed to ensure the facility's only dishwasher had the correct PPM of sanitizer to sanitize kitchen equipment. These failures could place residents at risk of ingesting chemicals and food-borne illnesses. Findings included:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 (Residents #44, #18, #60 and #9) of 6 residents reviewed for usage of wrist blood pressure monitor, as indicated by: The facility failed to ensure MA A cleaned and disienfected the wrist blood pressure monitor while using it on Resident #44 and Resident #18. The facility failed to ensure MA B cleaned and disienfected the wrist blood pressure monitor while using it on Resident #60 and Resident #9. This failure could place the residents at the facility at risk of transmission of disease and infection. Findings included: Review of Resident #44's face sheet, dated 10/30/23, reflected Resident #44 initially admitted to the facility on [DATE] and re admitted on [DATE]. She was a [AGE] year-old female diagnosed with Gastro-esophageal reflux Disease (Acid reflux), Hyperlipidemia (High fat level in blood), Type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all PASRR- Level I positive residents diagnosed with mental illness were provided with a PASRR- Level II Screening for 1 of 3 residents (Resident #39) reviewed for mental illness, intellectual disability, or developmental disability, in that: The facility failed to ensure Resident #39 received a PASRR Level 2 evaluation. This failure could place residents at risk for not receiving necessary mental health services, causing a possible decline in mental health. Findings included: Record review of Resident #39's face sheet dated 10/30/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included Anxiety Disorder, Hypertension, Paranoid Schizophrenia (a serious mental illness) and Cellulitis (Deep infection) of Left Lower Limb. Record review of Resident #39's MDS assessment dated [DATE] revealed a BIMS score of 09 out of 15 indicating the resident's cognition was moderately impaired. Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan addressed the resident's preferences, medical, physical, mental, and psychosocial well-being for 2 of 2 residents (Resident #9, Resident #56) reviewed for care plans in that: The facility did not ensure Resident #9's care plan addressed her preference to sleep in a recliner chair instead of a bed. The care plan indicated Resident #9 slept in a bed. The facility did not ensure Resident #56's care plan addressed that she was taking antipsychotic or antidepressant medication. This failure placed all residents at risk for unmet care needs. Findings include: Review of Resident #9's annual MDS assessment, dated 10/20/2023, reflected a 59 y/o female who was re-admitted on [DATE] and had a BIMS score of 15. Review of Resident #9's undated care plan reflected she had diagnosis of Diabetes II, Obstructive Sleep Apnea, Rheumatoid Arthritis and HTN. The care plan reflected that Resident #9 slept in a bed. Focus:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #49) of five residents reviewed for respiratory care, in that: The facility failed to change oxygen tubing weekly as ordered for Resident #49. This deficient practice could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Review of Resident #49's face sheet dated 11/01/23 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a type of progressive lung disease), Atrial Fibrillation (irregular heart rhythm) , Hyperlipidemia( Hight fat level in blood), Chronic Respiratory Failure with hypoxia ( low oxygen level in tissues) and Hypertension (high Blood pressure) , Review of Resident #49's quarterly MDS assessment, dated 10/14/23, reflected a BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.