McGregor Wellness & Rehabilitation

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record reviews the facility to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed for resident rights. The facility failed to ensure the MD and Hospice were notified when Resident #1 had a change of condition on [DATE] with blood in his foley catheter (a medical device, a thin flexible, sterile tube that is inserted through the urethra into the bladder to drain urine). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 3 residents review for catheter care. The facility failed to assess and intervene with Resident #1's foley catheter (a medical device, a thin flexible, sterile tube that is inserted through the urethra into the bladder to drain urine) when Resident #1's foley catheter was draining all blood from [DATE] until 3 days later on [DATE]; [...]

Inspectors wroteBased on interview and records review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 3 residents review for pain management. The facility failed to provide effective pain interventions for Resident #1 from [DATE] through [DATE]. The facility failed to assess and intervene when Resident #1's foley catheter (a medical device, a thin flexible, sterile tube that is inserted through the urethra into the bladder to drain urine) when Resident #1's foley catheter was draining all blood from [DATE] until 3 days later on [DATE]; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #1, Resident #2 and Resident #3 ) of 14 residents reviewed for accident hazards/supervision. There was one staff member in the memory care unit of the facility supervising 14 residents by herself., limiting adequate supervision for preventing accidents. An IJ was identified on 04/12/24. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including accurate acquiring, and administering of all drugs and biologicals to meet the needs for 1 (Resident#1) of 8 resident reviewed for pharmaceutical services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given Acyclovir for a total of 8 times, one post-dialysis dose of 400 MG on 10/16/2023, and seven 200 MG doses from 10/31/2023 through 11/05/2023. Resident #1 was not given Trifluridine a total of 59 times from 7/23/2023 through 11/28/2023, with 22 of the 59 missed Trifluridine doses having been missed in the month of November 2023. This failure resulted in the Resident #1's eye infection not healing effectively, and Resident #1 being considered for corneal transplant. An IJ was identified on 12/01/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 (Resident#1) of 8 resident reviewed for pharmaceutical services. The facility failed to follow prescribers' orders and professional standards and principles which apply to professionals providing services for Resident #1's scheduled medications. Resident #1 was not given Acyclovir for a total of 8 times, one post-dialysis dose of 400 MG on 10/16/2023, and seven 200 MG doses from 10/31/2023 through 11/05/2023. Resident #1 was not given Trifluridine a total of 59 times from 7/23/2023 through 11/28/2023, with 22 of the 59 missed Trifluridine doses having been missed in the month of November 2023. This failure resulted in the Resident #1's eye infection not healing effectively, and Resident #1 being considered for corneal transplant. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]