Macgregor Downs Health Center by Harborview

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to honor a resident's right to attend care plan meetings for 1 of 28 residents reviewed for care planning (Resident #53).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to clean and maintain window curtains, the flooring underneath medical equipment, and the packaged terminal air conditioner (PTAC) in a resident's room for 1 of 28 resident rooms (Resident #6) on 1 of 6 halls observed for environment.

Inspectors wroteBased on record review and interviews with staff, Nurse Practitioner, Physician, Responsible Party (RP), and Hospital Case Manager, the facility failed to allow Resident #129 to return the facility after being transferred to the hospital for evaluation for 1 of 4 residents reviewed for discharge (Resident #129).

Inspectors wroteBased on observations and staff interviews, the facility failed to store a sugar scoop in a manner that prevented the potential for cross contamination by storing the scoop in the bulk sugar bin with the scoop handle touching the sugar. This was for 1 of 3 pantry's observed. This had the potential to affect food served to residents.

Inspectors wrote2. Resident #57 active diagnoses included influenza. Review of the signage on the door to Resident #57's room read in part, Droplet Contact Precautions. Everyone must: Clean hands before entering and when leaving room. Wear a gown when entering the room and remove before leaving. Wear surgical/procedure mask when entering the room. Remove immediately before leaving room. Wear gloves when entering room. Perform hand hygiene after removing gloves. During observation on 2/9/25 at 10:56 AM the Director of Nursing entered Resident #57's room with no gown or gloves and a surgical/procedure mask, touched the privacy curtain while speaking with Resident #57, washed her hands, and left the room. [...]

Inspectors wroteBased on observation and staff and resident interviews, the facility failed to assess the ability of a resident to self-administer medications and vitamins for 1 of 1 resident with medications observed at bedside (Resident #42).

Inspectors wroteBased on record review, and resident, family and staff interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record and failed to provide written advance directive information and/or an opportunity to formulate an advance directive (Residents #105 and #114). This was for 2 of 4 residents reviewed for advance directive.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) for 1 of 3 residents reviewed for beneficiary notices (Resident #89).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop the comprehensive care plan in the area of pain for 1 of 28 residents (Resident #114) whose comprehensive care plans were reviewed.

Inspectors wroteBased on observations, record review, and staff and physician interviews, the facility failed to follow a physician's order for placement of a lidocaine (topical pain medication) patch on a resident's left hip when the patch was applied to the resident's back. This was for 1 of 2 residents (Resident #114) reviewed for professional standards of practice.

Inspectors wroteBased on record review, staff, resident and physician interview, the facility failed to clarify orders for blood sugar monitoring and insulin administration for short and long-acting insulins (insulin is a medication injected into the skin to control blood sugar) from the hospital discharge summary for a resident with a diagnosis of diabetes (Resident #81). This was for 1 of 2 residents reviewed for professional standards of practice.

Inspectors wrote2. Resident #92 was admitted to the facility on [DATE] with a diagnosis of heart failure. A review of Resident #92's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She had functional impairment in range of motion on one side of her upper extremities and both sides of her lower extremities. She required substantial assistance to roll from left to right in bed. She was always incontinent of bladder. She had no falls since her prior assessment. A review of a nursing progress note for Resident #92 dated 12/5/24 at 8:11 PM written by Nurse #1 indicated Resident #92 experienced a fall from bed at 6:00 PM that day. Nurse Aide (NA) #1 was present during the fall and provided Nurse #1 with a full statement of the incident. [...]

Inspectors wroteBased on observations, record review, and staff and family interviews, the facility failed to attempt alternatives to bed rail use and document how these alternatives failed to meet the resident's needs prior to the installation of bed rails. This was for 1 of 6 residents (Resident #114) reviewed for accidents.

Inspectors wroteBased on record review, staff and resident interviews the facility failed to assess for food preferences for 1 of 1 resident reviewed for food preferences (Resident #280).

Inspectors wroteBased on record review and staff interviews, the facility failed to have a complete and accurate Medication Administration Record (MAR) for 1 of 2 residents who received enteral formula (a method of providing nutrition directly into the gastrointestinal tract through a tube) who were reviewed for medical record accuracy (Resident #333).

Inspectors wroteBased on observation, record review and interviews with pest control staff, resident and facility staff, the facility failed to maintain an effective pest control program to prevent an infestation of mice and to protect a vulnerable resident from mice. On 7/1/24 Resident #18 was in bed when she felt something touch her foot. She pressed her call bell for assistance and when Nurse Aide (NA) #7 responded the NA pulled the blankets off the bed and a mouse jumped out of the bed and onto the floor. On 7/7/24 Resident #18 was in bed when NA #7 pulled the covers down to provide care and a mouse jumped out of the bed and onto the floor. On 7/26/24 Resident #18 saw a mouse running across the floor of her room. Resident #18 was shocked when the mouse was in her bed, and she was afraid of being bitten by a mouse. Mice are known to carry multiple diseases that can be life threatening. [...]

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to maintain an indwelling urinary catheter drainage tubing from touching the floor for 1 of 1 resident reviewed for indwelling urinary catheter use (Resident #14). This deficient practice placed the resident at increased risk for infection of the urinary system.

Inspectors wroteBased on observations and staff interviews the facility failed to prevent the potential for cross-contamination by storing plastic scoops inside dry ingredient bins allowing the handles to touch the dry ingredients for 2 of 2 observations.

Inspectors wroteBased on observation and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This was for one repeat deficiency in the area of Food Procurement, Store/Prepare/Serve-Sanitary (F812) originally cited on 5/14/21 during a recertification and complaint investigation survey and subsequently cited on 12/22/23 during the recertification and complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. This tag is cross referenced to: F812: [...]

Inspectors wroteBased on observation, record review and staff, resident, nurse practitioner, and podiatrist interviews, the facility failed to notify the resident's physician of a change in condition for 1 of 1 resident (Resident #118) reviewed for Notification of Changes. Resident #118 experienced bleeding following the debridement of her right great toenail. This change in condition was not reported to the resident's attending Physician or the Podiatrist.

Inspectors wroteBased on record review, resident, staff, family, responsible party, and police detective interviews the facility failed to prevent misappropriation of resident property when a nurse aide (NA #8) took resident's credit cards and used them without permission to make purchases. This was for 2 of 2 residents (Resident #286 and Resident #12) reviewed for misappropriation.

Inspectors wroteBased on record review and, staff, family, responsible party, and police detective interviews the facility failed to implement their abuse policy and procedure by failing to maintain evidence of proof of preemployment screening and failing to maintain documentation of a complete and thorough investigation of allegations of misappropriation. This was for 2 of 2 residents (Resident #286 and Resident #12) reviewed for misappropriation.

Inspectors wroteBased on observation, record review and staff, and resident interviews the facility failed to complete an accurate assessment for 1 of 1 resident reviewed. Resident #118 experienced bleeding following the debridement of her right great toenail.

Inspectors wroteBased on record review and resident, staff, Responsible Party and the Vaccine Distribution and Help Desk Supervisor at the North Carolina Immunization Registry interviews the facility failed to provide education regarding the benefits and possible side effects of a pneumococcal vaccine, offer a pneumococcal vaccine, and then document either a refusal or the administration of a pneumococcal vaccine for 1 of 5 residents (Resident #19) reviewed for immunizations.

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to have care plan meetings for 1 of 2 residents reviewed for care plan meetings (Resident #2).