Mcintosh Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Mcintosh Care and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 19, 2026

  Based on observations, record review and interviews, the facility failed to ensure one (#88) of three residents reviewed for accidents received adequate supervision out of 38 sample residents. Resident #88 was admitted on [DATE] with diagnoses cerebral infarction (stroke), acute respiratory failure, atrial fibrillation, pacemaker, osteoarthritis, obesity, hypertension and acute kidney failureOn 12/16/26, Resident #88 was being transported to an appointment in the facility's transportation van. Resident #88's wheelchair was not properly secured in the transportation van. During the transportation, Resident #88's wheelchair slipped and the resident hit her head on the van. […]

• Actual harm, isolatedF689Nov 17, 2022

  Based on interviews, record review, and facility policy review, the facility failed to provide adequate supervision and assistance to prevent accidents for 2 (Resident #122 and Resident #224) of 4 sampled residents reviewed for falls/accidents. Specifically, the facility assessed Resident #122 to be at high risk for falls upon admission but did not develop interventions to prevent falls, and on 6/8/2022 (five days after admission to the facility) Resident #122 fell and sustained a [CONDITION(S)]. Additionally, the facility assessed Resident #224 to require the assistance of two staff for transfers; however, an incident report revealed the resident sustained an injury to the knee during a transfer with the assistance of only one staff person. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF689Jul 22, 2021

  Based on observations, staff interviews and record review, the facility failed to ensure two residents (#60 and #30) out of five sampled residents out of 37 sample residents and four out of four hallways for water temperatures exceeding 120 degrees Fahrenheit (F), were as free from accident hazards as possible and received adequate supervision and assistive devices to prevent accidents. Specifically the facility failed to: -Ensure the water temperatures were not in excess of greater than 120 degrees F. […]

• No harm, potential for more than minimal, widespreadF725Jul 22, 2021

  Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility had delayed call light response, failed to provide assistance with activities of daily living (ADLs) including baths and meal assistance and call lights answered timely. […]

• No harm, potential for more than minimal, widespreadF802Jul 22, 2021

  Based on observations, staff interviews and record review, the facility failed to employ sufficient dietary support staff to carry out the functions of the food and nutrition services department in one of one facility kitchens. Specifically, the facility failed to ensure: -The dietary department had sufficient numbers of adequately trained food and nutrition staff to ensure safe and sanitary food service; and, -The dietary department had sufficient staff to ensure the meals were prepared and served according to the posted meal times. Findings include: I. Observations The posted meal time for the dinner meal was 5:30 p.m. 7/18/21 -At 4:45 p.m, the initial kitchen tour showed it was staffed with one cook and one dietary aide. -At 5:30 p.m., the first meal in the dining room was served. […]