Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcgregor Wellness & Rehabilitation during CMS and state inspections, most recent first.
Food storage and service practices were not followed in the kitchen. Multiple items in coolers, freezers, and dry storage were found unlabeled, undated, unsealed, or exposed to air, and several foods lacked required discard or expiration dates. Cases of canned goods were stacked on the floor, hamburger meat was thawed in a sink used for dishes and was hot to the touch, and the temperature of a pan of meatloaf was not taken before it was served. Interviews with the DA, CK, DM, RDM, and ADM confirmed staff were responsible for labeling, dating, thawing, storing, and checking food temperatures.
MDS Did Not Reflect Pressure Ulcer Status: A resident with diabetes, severe cognitive impairment, and generalized weakness had an MDS that marked pressure ulcer risk but did not code an actual pressure ulcer or skin breakdown. Staff interviews confirmed the resident had a stage 3 pressure ulcer that had previously been stage 4, while the care plan did not reflect the wound and the MDS Coordinator stated the matrix was the source for MDS coding.
Surveyors found that kitchen staff, including the KD and cooks, prepared and handled food with exposed mustaches and failed to change gloves after touching non-food surfaces such as clothing, cell phones, and books. Facility policy required all hair, including facial hair, to be covered with hair nets, caps, or beard restraints and specified that gloves were single-use and must be changed between tasks with appropriate handwashing. In interviews, the KD acknowledged these requirements and the potential for hair and improper glove use to cause resident illness, while one cook reported he was unaware his mustache needed to be covered and was unsure if hair restraint training was included in his food handler education. The ADM and DON confirmed that the KD was responsible for staff training on hygiene and that all hair was to be covered to prevent contamination of food.
A resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all identified needs. Surveyors observed that the care plan did not fully ensure comprehensive care for the resident.
A resident with multiple complex medical conditions, including an indwelling Foley catheter, experienced blood in the catheter and increased pain. Despite several staff members being aware of these changes, there was no timely notification to the physician, hospice, or family. The resident was later hospitalized with sepsis, acute urinary retention, and a complicated UTI, and subsequently died. The failure to follow notification protocols led to an Immediate Jeopardy finding.
A resident with multiple comorbidities and an indwelling Foley catheter experienced several days of blood in the catheter and minimal urine output, accompanied by pain and discomfort. Despite these signs, staff did not consistently assess, document, or escalate the change in condition to medical providers or hospice, resulting in delayed intervention. The resident was eventually hospitalized with sepsis, acute urinary retention, and a complicated UTI, and later expired in inpatient hospice care.
A resident with multiple comorbidities and an indwelling catheter experienced ongoing pain and blood in the catheter bag for several days, with staff observing but not documenting or escalating the change in condition. Pain medications were not administered as needed, and the hospice nurse was not notified in a timely manner. The resident was eventually sent to the ER, diagnosed with sepsis, acute urinary retention, complicated UTI, and dehydration, and later died in the hospital. Staff interviews revealed a lack of adherence to pain assessment, documentation, and notification protocols.
An LVN in an LTC facility failed to follow proper hand hygiene protocols during a medication pass, leading to a breach in infection control. The LVN did not remove gloves or wash hands between handling the PEG tube of one resident and the G-tube of another, both of whom were dependent on feeding tubes due to their medical conditions. This failure was acknowledged by the LVN and highlighted by the DON as a risk for cross-contamination and infection.
The facility failed to maintain professional standards for food safety, with staff not wearing proper hair restraints, air vents covered in grease, and hazardous chemicals stored near food prep areas. The industrial can opener was unclean, and the dishwasher had insufficient chlorine levels, risking inadequate sanitization. Lack of communication and oversight contributed to these deficiencies.
The facility failed to provide adequate supervision and assistance devices to prevent accidents in the memory care unit, where one staff member was responsible for 14 residents. This led to an incident where one resident attempted to hit another, and residents were observed moving in and out of the courtyard without supervision. The facility's staffing schedule and policies were not adhered to, resulting in compromised care and an Immediate Jeopardy situation.
Food Storage, Labeling, Thawing, and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation of the walk-in cooler, freezer, dry goods pantry, standalone freezer, kitchen, and standalone refrigerator, multiple food items were found without proper labels, dates, or seals. Examples included white gravy labeled only with a date and no expiration date, chicken nuggets in a Ziploc bag with no date, opened butter wrapped in Saran Wrap with no open or expiration date, sweet corn dated only with a month and year, an unsealed bag of herbs with no opening or expiration date, lasagna in a foil pan dated with no expiration date, pasta in a Ziploc bag without contents identified and no expiration date, bread without open or expiration dates, and an uncovered single-serve ice cream cup that was exposed to air and not labeled or dated. The dry goods pantry also contained five cases of canned goods stacked on the floor. In the kitchen, clear plastic bins of single-serve ketchup, mayonnaise, syrup, and jelly packets were not labeled or dated. A tube of hamburger thawed meat was observed in the sink used for rinsing dishes, and it was hot to the touch with no cold water running over it. In the standalone refrigerator, opened butter was not sealed and was exposed to air, and a loaf of bread was not labeled with an open date or expiration date. Food service temperature monitoring was also not completed as required. During observation of meal service, the temperature of one pan of meatloaf was not taken on the warming cart before it was served to residents. Interviews with the DA, CK, DM, RDM, and ADM confirmed that staff were responsible for labeling and dating food, properly thawing frozen meat in the refrigerator or under cold running water, keeping food off the floor, and taking temperatures of food on the warming tray before serving. The facility's policies reflected requirements for labeling, dating, proper storage, and taking food temperatures before service.
MDS Did Not Reflect Resident’s Pressure Ulcer Status
Penalty
Summary
The facility failed to ensure Resident #4’s assessment accurately reflected her status by not coding a pressure ulcer in the MDS. Resident #4 was an [AGE]-year-old female admitted on [DATE] with diagnoses including type 2 diabetes mellitus without complications, hypokalemia, hyperlipidemia, unspecified, and generalized muscle weakness. Her Quarterly MDS dated 01/07/2026 showed a BIMS score of 00, indicating severe impairment, and Section M0150 was marked yes for risk of pressure ulcers/injuries. Record review showed Resident #4’s comprehensive care plan, last revised on 06/04/2025, did not reflect a pressure ulcer or skin breakdown. During interviews, the ADON stated Resident #4 had a stage 3 pressure ulcer and that it had previously been stage 4 before the NP downgraded it to stage 3. The ADON also stated the NP and wound care nurse rounded together on Mondays. The MDS Coordinator stated she was responsible for making sure the matrix was correct, that the matrix was updated daily, and that she did not think an incorrect matrix would affect care. The Wound Care Nurse stated he looked at Resident #4 and it was a skin breakdown, and he stated if the resident was not on the matrix, they would not get the appropriate care.
Improper Hair Restraints and Glove Use During Food Preparation
Penalty
Summary
Surveyors identified a deficiency in food service safety practices involving the kitchen director (KD) and two cook staff (CO B and CO C), who did not follow the facility’s policy and professional standards for hair restraints and glove use while preparing and handling food. During a lunch preparation observation, the KD, CO A, and CO B were seen wearing face coverings that did not cover their mustaches, leaving facial hair exposed while they prepared lunch. The KD and CO A were also observed touching multiple non-food surfaces, including clothing, a cell phone, and books, while wearing the same gloves used for food preparation and did not change those gloves. The facility’s written policy required hair nets, caps, and/or beard restraints to keep hair from contacting exposed food, equipment, utensils, and linens, and specified that gloves were single-use items that must be discarded after completing a task, with handwashing required to prevent cross-contamination. In interviews, the KD acknowledged that the policy required no visible hair, including facial hair, and stated that hair falling into food was a risk that could lead to resident sickness, cross contamination, and choking. He also stated that gloves should be changed when dirty, when something spilled on them, or when switching tasks, and that failure to change gloves could lead to resident illness. CO B reported he was unaware his mustache had to be covered, was unsure if hair restraints were addressed in his food handler training, and did not know the specifics of the policy, despite having started nearly two months earlier. CO C, who started in August 2023, stated he understood that beards and mustaches were to be covered and that uncovered hair could spread germs and get residents sick; his records showed he attended an in-service with a kitchen safety quiz, while there was no documentation of CO B’s participation. The ADM and DON both confirmed that all hair was to be covered and that the KD was responsible for training kitchen staff on hygiene and hair restraints, and both stated that residents could get sick from hair in their food.
Incomplete Care Plan Development and Implementation
Penalty
Summary
The deficiency identified is the failure to develop and implement a complete care plan that addresses all of a resident's needs, including the establishment of measurable timetables and specific actions. The report notes that the care plan was either incomplete or lacked sufficient detail to ensure that all aspects of the resident's care requirements were met. This omission was observed during the survey process and was based on a review of the resident's records and care documentation.
Failure to Notify Physician and Hospice of Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the physician and hospice team of a significant change in a resident's condition, specifically the presence of blood in the resident's indwelling Foley catheter. Despite multiple staff members, including CNAs and LVNs, being aware of the blood in the catheter and the resident's discomfort and pain, there was no documentation or evidence that the physician, hospice nurse, or the resident's family were promptly informed of this change. The issue was reported by the resident's family, who observed blood in the catheter and communicated this to nursing staff, but were told that hospice would be notified later due to weekend staffing. The resident in question had a complex medical history, including Parkinson's disease, acute kidney failure, obstructive and reflux uropathy, benign prostatic hyperplasia, and a history of urinary tract infections. The care plan required staff to monitor for signs and symptoms of urinary tract infection and to notify the charge nurse and physician for further assessment. Despite these directives, staff did not follow the notification protocol when the resident exhibited significant changes, such as blood in the catheter, low urine output, and increased pain. Interviews with staff revealed that the change in condition was passed on during shift reports but not escalated to the physician or hospice as required by facility policy. As a result of the lack of timely notification and intervention, the resident was eventually sent to the emergency room, where he was diagnosed with sepsis, acute urinary retention, complicated urinary tract infection, and dehydration. The resident was admitted to inpatient hospice care at the hospital and subsequently died. The facility's failure to notify the appropriate parties in a timely manner was identified as an Immediate Jeopardy situation by surveyors.
Failure to Assess and Intervene for Catheter-Related Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of Parkinson's disease, acute kidney failure, obstructive and reflux uropathy, BPH, and recurrent urinary tract infections, who was dependent on an indwelling Foley catheter, did not receive appropriate assessment and intervention for changes in catheter output and condition. Over a period of several days, the resident's catheter was noted to be draining blood with minimal to no urine output, and the resident exhibited signs of discomfort and pain, including abdominal distension and moaning. Despite these changes, there was a lack of timely documentation, assessment, and escalation to medical providers or hospice, as required by facility policy and professional standards. Multiple staff members, including LVNs and CNAs, observed and were aware of the presence of blood in the catheter and the resident's discomfort, but interventions were either not documented or not performed according to protocol. Communication among staff was inconsistent, with information about the resident's condition being passed verbally from shift to shift without proper documentation or notification to the physician or hospice nurse. The hospice nurse was not informed of the ongoing issues until several days after the initial change in condition, and the resident was not sent to the emergency room until the situation had significantly deteriorated. Upon eventual transfer to the hospital, the resident was diagnosed with sepsis, acute urinary retention, complicated UTI associated with the indwelling catheter, and dehydration. The hospital records indicated that the catheter was not properly draining due to displacement, and the resident's symptoms were managed with IV medication in inpatient hospice care, where the resident later expired. The facility's failure to assess, document, and intervene appropriately in response to the resident's change in condition led to the identification of an Immediate Jeopardy situation.
Failure to Provide Safe and Appropriate Pain Management for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident who required such services, resulting in a deficiency. The resident, an elderly male with a history of Parkinson's disease, acute kidney failure, obstructive and reflux uropathy, BPH, and recurrent UTIs, was admitted with an indwelling catheter and was at risk for pain due to his disease process. Despite care plan interventions that included monitoring for signs and symptoms of UTI, administering analgesia as ordered, and responding immediately to complaints of pain, staff did not adequately assess or intervene when the resident's foley catheter began draining blood over a period of three days. Documentation revealed that the resident experienced almost constant pain, rated 7 out of 10, and exhibited nonverbal signs of pain such as moaning, grimacing, and agitation. However, there was no documentation of a change in condition or appropriate pain interventions during this period. Multiple staff members, including CNAs and LVNs, were aware of the resident's condition, noting blood in the catheter bag, low urine output, and the resident's discomfort and pain, particularly in the abdominal area. Despite these observations, the staff did not document the change in condition or notify the physician or hospice nurse in a timely manner. The resident's pain medications, including PRN and scheduled doses, were not administered as needed, and there was a lack of documentation regarding the effectiveness of pain interventions. The hospice nurse was not informed of the presence of blood in the catheter until several days later, at which point the resident was transferred to the ER, diagnosed with sepsis, acute urinary retention, complicated UTI, and dehydration, and subsequently died in the hospital. Interviews with staff revealed a lack of adherence to facility policy regarding pain assessment, documentation, and notification protocols. Staff reported passing information about the resident's condition from shift to shift without formal documentation or escalation. The facility's policies required timely assessment and intervention for pain, especially for nonverbal residents, and mandated communication with hospice and the physician in the event of significant changes. These protocols were not followed, resulting in a failure to provide effective pain management and appropriate clinical response to the resident's deteriorating condition.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the actions of LVN A during a medication pass. LVN A did not adhere to proper hand hygiene protocols, which are crucial for preventing the transmission of infections. Specifically, LVN A failed to remove her gloves and wash her hands before donning a new set of gloves after touching the PEG tube of one resident and then the G-tube of another resident. This lapse in protocol was observed during an interaction with two residents who were dependent on feeding tubes due to their medical conditions. Resident #1, a male with a history of supraventricular tachycardia, anoxic brain damage, and traumatic brain injury, was dependent on a PEG tube for nutrition due to dysphagia. Resident #2, also a male, had reduction deformities of the brain and cerebral palsy, requiring a G-tube for nutritional support. The facility's infection control policy mandates handwashing or the use of an alcohol-based hand rub before and after direct contact with residents and after removing gloves. However, LVN A admitted to not following these procedures, which was corroborated by the Director of Nursing, who emphasized the risk of cross-contamination and infection if proper hand hygiene is not practiced.
Deficiencies in Kitchen Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, leading to several deficiencies. Observations revealed that staff members, including the Director of Maintenance (DOM) and Kitchen Assistant (KA A), were not wearing effective hair restraints while in food preparation areas. This lack of proper hair covering could lead to hair contamination in the food served to residents. Additionally, the facility's air vents were found to be covered in grease and debris, posing a risk of contamination to food and clean dishes. Further inspection showed that hazardous chemicals, such as metal polish, cleaner with bleach, and PVC cement, were stored too close to the food preparation area, increasing the risk of chemical contamination. The facility's industrial can opener was coated with a black sticky substance, indicating it had not been cleaned properly. The dishwasher, essential for sanitizing kitchen equipment, was not maintained correctly, with lime buildup and insufficient chlorine levels in the sanitizing cycle, which could lead to inadequate sanitization of dishes. Interviews with kitchen staff and management revealed a lack of communication and oversight regarding cleaning schedules and maintenance issues. The Kitchen Manager (KM) admitted to not logging maintenance issues or ensuring the cleaning schedule was followed, leading to the oversight of critical cleaning tasks such as the air vents and dishwasher. The facility's failure to maintain a clean and safe kitchen environment could potentially expose residents to food-borne illnesses and chemical ingestion.
Inadequate Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents in the memory care unit. One staff member was responsible for supervising 14 residents, which limited the ability to prevent accidents. This lack of supervision led to an incident where one resident attempted to hit another, and the staff member had to intervene to prevent physical harm. Additionally, residents were observed moving in and out of the courtyard without supervision, and the door to the courtyard remained open for their convenience. Resident #1, a female with severe cognitive impairment, was at risk for falls, wandering, and conflictual behavior. She required extensive assistance for daily activities and had a history of wandering and impulsive behavior. Resident #2, a female with moderate cognitive impairment, exhibited verbal and other behavioral symptoms and required extensive assistance for daily activities. She was also at risk for elopement and falls. Resident #3, a male with severe cognitive impairment and total dependence on staff for daily activities, required full support for eating, bed mobility, and transfers. The facility's staffing schedule revealed that only one CNA was scheduled for the memory care unit on multiple days, leading to compromised care. Interviews with staff members confirmed that the single CNA struggled to provide adequate supervision and care for all residents. The facility's policies on safety, supervision, and staffing were not adhered to, resulting in an Immediate Jeopardy (IJ) situation. The facility's administrator did not believe the care was compromised, despite evidence to the contrary. The IJ was identified and later removed after corrective actions were implemented, but the facility remained out of compliance due to ongoing monitoring of the corrective systems.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mc Gregor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Joseph's Care Center | 0.2 mi | — | 2 | 0 |
| Wesley Woods Health & Rehabilitation | 12.4 mi | ★★★★★ | 7 | 0 |
| Avir At Waco | 12.8 mi | ★★★★★ | 7 | 0 |
| Ridgecrest Retirement And Healthcare Community | 13 mi | ★★★★★ | 0 | 0 |
| Hewitt Nursing And Rehabilitation | 13.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.