Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Macgregor Downs Health Center By Harborview during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was found to be living in a room where window curtains had scattered red stains, dried brown liquid remained on the floor beneath a tube feeding pole, and the PTAC unit contained visible dust-like black debris on and inside the vents. Over multiple days, housekeeping staff either did not recognize or did not effectively address these issues, with one housekeeper attempting but failing to remove the hardened brown liquid and not reporting the stained curtains, and another focusing only on trash and flooring and reporting that everything appeared fine. The housekeeping manager and administrator later acknowledged that these cleanliness concerns should have been identified and corrected, and that the window curtains were old and awaiting replacement.
A resident with Parkinson’s disease, dementia, significant visual and hearing impairment, and multiple comorbidities, who had no prior documented aggressive behaviors, was observed by nursing staff in an aggressive incident with a roommate and was sent to the hospital for evaluation. ED and psychiatric assessments found no acute psychiatric illness and cleared the resident for SNF-level care, while ED case management notes show the facility first indicated the resident could return once a private room was available, then later stated he would not be accepted back. The resident’s spouse reported being told by hospital staff that the facility refused readmission and by the DON that there was no appeal or recourse. Facility social workers and admissions staff stated they were not involved in the decision, which the Administrator and DON acknowledged making based on the incident and hospital records, without contemporaneous physician documentation that the facility could not meet the resident’s needs. The resident ultimately did not return and was discharged home with home health services arranged by the hospital.
Failure to Invite Resident to Care Plan Meeting: A resident with moderate cognitive impairment was not invited to care plan meetings. The SW said only the listed RP was invited unless the resident was their own RP, while the resident stated she wanted to attend to better understand her situation and felt her RP was not acting in her best interest. The care plan meeting was held with only the IDT present, and the RP did not attend.
The facility failed to prevent potential cross contamination by improperly storing a sugar scoop in the bulk sugar bin with the handle touching the sugar. A dietary aide and the dietary manager confirmed that the scoop should be stored separately. A staff member admitted to accidentally leaving the scoop in the sugar after use, which was acknowledged by the administrator.
The facility failed to adhere to infection control policies, with staff not wearing required PPE or performing hand hygiene in rooms with residents on droplet precautions. A housekeeper, the DON, a nurse, and an administrative ambassador entered rooms without proper PPE, and a nurse failed to perform hand hygiene before and after glove use. The facility lacked documentation of infection control training for one nurse.
The facility failed to document and communicate advance directives for two residents, one cognitively intact and the other severely impaired. Staff interviews revealed confusion over responsibility for discussing and documenting advance directives, resulting in a lack of documentation in residents' records. The facility's policy on advance directives was not effectively implemented, leading to deficiencies in supporting residents' rights.
Two residents in an LTC facility rolled out of bed during care due to improper turning techniques by nurse aides, resulting in injuries such as skin tears and a hematoma. Both residents were cognitively intact and required assistance with bed mobility. The facility failed to ensure staff followed proper procedures, and comprehensive corrective actions were not implemented.
A resident with multiple diagnoses was found with medication cups at her bedside without a self-administration assessment or physician's order. The nurse left the medications intending to return but forgot, leaving the resident unsure which medications to take. The DON confirmed that medications should not be left at the bedside, leading to a deficiency.
A facility failed to provide a SNF/ABN to a resident after their Medicare Part A coverage ended. The resident continued to stay in the facility without being informed of their financial responsibility for services not covered by insurance. Staff interviews confirmed the oversight.
A facility failed to include pain management in a comprehensive care plan for a resident with a left leg fracture and severe cognitive impairment. Despite constant pain affecting the resident's sleep and activities, the care plan lacked a focus on pain, which was an oversight acknowledged by the MDS Coordinator and confirmed by the DON.
A resident with a left leg fracture and severe cognitive impairment experienced a deficiency in care when a nurse applied a lidocaine patch to the resident's back instead of the left hip as per the physician's order. The nurse acted on the resident's request without obtaining a new order, which was confirmed as inappropriate by the DON, the physician, and the administrator.
A facility failed to implement diabetes management orders for a resident, resulting in a lack of blood sugar monitoring and insulin administration. The admissions nurse overlooked the hospital discharge instructions, and the resident's physician was unaware of the need for these orders until later. The Director of Nursing noted that the admissions process was not followed correctly.
A facility failed to attempt and document alternatives to bed rail use for a resident with severe cognitive impairment and a left leg fracture. The resident's family consented to bed rail use without being informed of alternatives. Interviews with staff revealed a lack of awareness and discussion about alternatives, indicating a systemic issue in the facility's approach.
A resident, moderately cognitively impaired, reported receiving unwanted pork products due to the facility's failure to assess and document her food preferences. The Dietary Manager confirmed the absence of documented preferences and noted that an assistant previously responsible for these assessments was no longer available. The Administrator expected the Kitchen Manager to conduct these assessments upon admission, which was not done for this resident.
A resident receiving enteral nutrition had an inaccurate MAR entry when a nurse began administering the formula, but the resident refused it. Despite the refusal, the MAR indicated the dose was given. Interviews with staff confirmed that refusals should be documented, highlighting a failure in accurate record-keeping.
A resident with limited mobility experienced multiple incidents of mice in her bed due to the facility's ineffective pest control program. Despite weekly pest control services, mice were found in the resident's room, and staff communication and documentation were inadequate. The issue was linked to nearby construction, and the facility's measures to address the problem were insufficient.
A resident with obstructive and reflux uropathy was found with urinary catheter drainage tubing lying on the floor, posing an infection risk. Despite care plans and staff training, the tubing was improperly positioned, indicating a deficiency in infection control practices. Staff interviews revealed a lack of awareness and oversight regarding the tubing's position.
Failure to Maintain Clean Curtains, Flooring, and PTAC in a Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and comfortable environment in one resident’s room, including failure to properly clean window curtains, flooring under medical equipment, and the PTAC unit. The resident involved had a quarterly MDS indicating severe cognitive impairment. On multiple observations over three consecutive days, surveyors noted two window curtains with scattered red stains, two pools of dried brown liquid on the floor underneath the tube feeding pole near the head of the bed, and dust-like black bits, fragments, and pieces on and inside the PTAC near the filter insertion site. These conditions remained unchanged across observations on 4/27, 4/28, and 4/29. Housekeeper #1, primarily assigned to that hall and to the resident’s room on two of the three days, stated that housekeeping duties included trash removal, sweeping, mopping if there was a spill, bathroom cleaning, changing hand sanitizer, and replenishing bathroom supplies, and that housekeeping was responsible for identifying stained window curtains and PTAC cleaning. During an in-room interview, Housekeeper #1 confirmed the stained curtains, dried brown liquid on the floor, and dusty black substance on and inside the PTAC, and reported she had attempted but failed to remove the hardened brown liquid and had not notified the Housekeeping Manager/Maintenance Director about the stained window curtains. She also stated she had not been instructed to inspect window curtains and had confused them with privacy curtains. Housekeeper #2, who cleaned the room on the intervening day, reported focusing only on trash and flooring and stated everything looked fine. The Housekeeping Manager/Maintenance Director and Administrator both acknowledged that the cleanliness issues in the room should have been identified and addressed, and that the window curtains were old and in the process of being replaced.
Failure to Allow Hospitalized Resident to Return After Clearance for SNF-Level Care
Penalty
Summary
The deficiency involves the facility’s failure to allow Resident #129 to return to the facility after a hospital transfer, despite the hospital determining he was appropriate for skilled nursing facility (SNF) level of care. Resident #129 had multiple chronic conditions, including Parkinson’s disease, bilateral sensorineural hearing loss, bilateral unqualified visual loss, hypertension, diabetes mellitus, hyperlipidemia, dementia, anxiety disorder, depression, and asthma. His medical record from admission through 4/18/26 showed no evidence of behaviors. A late entry nursing note dated 4/20/26 documented that on 4/19/26 he was observed kneeling on the floor over his roommate, appearing very aggressive and intending harm. The two residents were separated, assessed with no injuries noted at that time, the provider and responsible parties were notified, and Resident #129 was sent to the hospital for evaluation. Interviews with multiple nurse aides indicated that prior to this incident, Resident #129 had not exhibited aggressive or violent behaviors toward other residents. Staff reported that he could become irritable and yell at staff to leave his room, but he would calm down and apologize after a short period, and they were surprised to learn of his aggression toward his roommate. One nurse aide recalled that during the incident the nurse had already separated the residents when she entered the room, and she observed the roommate with a small laceration near the left eye that healed within two days. Law enforcement was notified, and Resident #129 was transferred to the hospital. A transfer/discharge notice was provided to him, stating that the transfer/discharge was necessary for his welfare, that his needs could not be met in the facility, and that the safety of individuals in the facility was endangered due to his clinical or behavioral status. Hospital records from 4/19/26 through 4/21/26 showed that Resident #129 was evaluated in the Emergency Department (ED) for agitation. A psychiatry and behavioral medicine consultation noted his history of Parkinson’s disease with worsening confusion, no prior psychiatric history of aggression or agitation, and his report that he became upset when he found someone in his bed. The psychiatric evaluation found no acute psychiatric illness and that he did not meet criteria for inpatient admission. ED documentation also noted that he was blind and hard of hearing. ED case management notes indicated that the facility initially stated he could return when a private room became available the next day, but later informed the hospital that he would not be allowed to return at all. The ED/Behavioral Health Case Manager confirmed that the ED providers had cleared him for SNF-level care and that the facility’s hospital liaison, after consulting with the Administrator, stated the resident could not return. The resident’s responsible party (his spouse) reported being informed by the facility nurse that he was being sent to the hospital for confusion, delusions, and anger toward his roommate. She stated that a hospital case manager later told her the facility initially required a 24-hour wait for a private bed, then later said the resident would not be accepted back, and that other facilities were not accepting him. She reported being told by the hospital that he had to go home, and that when she spoke with the facility’s Director of Nursing she was told she had no appeal or recourse. Social workers at the facility stated they were not involved in decisions about whether a resident could return, indicating that such decisions were handled by Admissions, the Administrator, and the Director of Nursing. The Admissions Director and Admissions Ambassador both stated they had no role in deciding whether a resident was allowed to return and that the decision regarding this resident was made by the Administrator and Director of Nursing. The Nurse Practitioner stated she was informed of the incident the following morning and was not involved in the decision to refuse readmission, but agreed with the conclusion that the facility could not provide the level of care he needed at that time, citing his cognitive decline and visual impairment and the concern that he could again attack someone if he misperceived a situation. The Physician similarly stated that the decision not to allow the resident to return was made by the Director of Nursing and Administrator without his involvement; he was informed afterward and agreed with the decision but did not document that the facility could not care for the resident. The Administrator reported that the decision not to allow Resident #129 back was based on the incident and the hospital records, which showed only a psychiatric assessment and clearance to return the same day. She stated she believed the facility could not guarantee the safety of other residents if he returned and confirmed that the facility’s hospital liaison informed the hospital that the resident would not be returning. There was no documentation in the report that the facility completed or documented a comprehensive assessment demonstrating that the resident’s needs could not be met in the facility or that the safety of individuals was endangered in a manner that justified refusing his return after the hospital cleared him for SNF care. As a result, Resident #129 did not return to the facility and was ultimately discharged home with his spouse with home health services arranged by the hospital. The responsible party expressed concern that he did not receive additional therapy before returning home but stated he did not appear to have psychosocial harm and was doing “okay” at home. The deficiency centers on the facility’s failure to allow the resident to return following a hospital transfer, despite the ED’s determination that he was appropriate for SNF-level care and the lack of prior documented aggressive behavior in the facility record, and on the decision-making process by the Administrator and Director of Nursing that led to his non-readmission without documented physician involvement at the time of the decision or documented evidence that the facility could not meet his needs.
Failure to Invite Resident to Care Plan Meeting
Penalty
Summary
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. Resident #53 was admitted to the facility and the quarterly MDS assessment identified her as moderately cognitively impaired. Her care plan was initiated on 2/12/24 and last revised on 3/26/26. A late entry note by Social Worker #1 stated a care plan meeting was held with only the IDT, consisting of the facility Social Worker and the MDS Nurse, in attendance, and that the Responsible Party was invited but did not attend. The record also showed advanced directives and code status were reviewed. During interview, Resident #53 stated she did not get invited to care planning meetings and said attending would help her better understand her current situation because she felt her RP was not acting in her best interest. Social Worker #1 stated she did not invite the resident because the resident was not listed as her own RP and that only the listed RP was invited; she said the resident would only be invited if listed as her own RP. The Administrator stated he expected staff to send care plan meeting invitations to residents who had the cognitive ability to participate and for whom participation would have been meaningful.
Improper Storage of Sugar Scoop in Pantry
Penalty
Summary
The facility failed to store a sugar scoop in a manner that prevented potential cross contamination. During an observation in Hall 2 pantry, the sugar scoop was found stored directly in the bulk sugar bin with the handle in contact with the sugar. Dietary Aide #1, who was assigned to the Hall 2 pantry, stated that the scoop was not in the sugar when she went on her break earlier that day. She acknowledged that the scoop should always be stored separately to maintain sanitary conditions and prevent cross contamination. The Dietary Manager confirmed that the scoop should never be stored in the sugar bin to avoid contamination. [NAME] #1 admitted to using the sugar from the bulk bin to make sweet tea for the residents' supper meal and acknowledged that he accidentally left the scoop in the sugar. The Administrator also confirmed that the scoop should not be stored in the sugar bin after use and stated that [NAME] #1 was aware of this protocol. This incident was observed and reported by surveyors, indicating a deficiency in the facility's food storage practices.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection control policies and procedures, as evidenced by multiple staff members not adhering to droplet contact precautions. Housekeeper #1 was observed cleaning the room of two residents diagnosed with Influenza A without wearing an isolation gown, despite signage indicating the need for a gown, mask, and gloves. The Director of Nursing (DON) also entered a resident's room on droplet precautions without the required gown and gloves, mistakenly believing it was an enhanced barrier precautions room. Further observations revealed that Nurse #3 and the Administrative Ambassador entered the room of two residents on droplet precautions without performing hand hygiene or donning the necessary PPE. Both individuals acknowledged their oversight, with Nurse #3 expressing concern over a beeping noise and the Administrative Ambassador admitting awareness of the signage and policy. The DON confirmed that all staff had been trained on infection control practices, including the use of PPE. Additionally, Nurse #1 failed to perform hand hygiene before and after glove use during a blood glucose check, and used a glove that had fallen on the floor, which is considered contaminated. The DON reiterated the importance of hand hygiene and proper glove use, noting that anything dropped on the floor should not be used on residents. The facility was unable to find documentation of Nurse #1's infection control training since her hire date.
Failure to Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives were properly documented and communicated, as evidenced by the cases of two residents. Resident #105, who was cognitively intact, did not have documentation in her record regarding education or opportunities to formulate advance directives. Interviews with various staff members, including social workers and the admissions nurse, revealed a lack of clarity and responsibility regarding who was tasked with discussing and documenting advance directives. Each staff member believed it was someone else's responsibility, leading to a gap in the resident's care plan. Similarly, Resident #114, who was severely cognitively impaired, did not have any documentation of discussions about advance directives in his medical record. His family member confirmed that no one from the facility had discussed or requested copies of existing advance directive documents, such as a living will or health care power of attorney. Interviews with the admissions nurse, admissions director, and social workers indicated that there was no consistent process for addressing advance directives during the admissions process, resulting in the absence of these critical documents in the resident's record. The facility's policy on residents' rights regarding treatment and advance directives was not effectively implemented, as evidenced by the lack of documentation and communication about advance directives for the two residents reviewed. The staff interviews highlighted a lack of clear responsibility and communication among the team members, leading to the failure to support and facilitate residents' rights to formulate and document advance directives as per the facility's policy.
Inadequate Supervision Leads to Resident Falls During Care
Penalty
Summary
The facility failed to provide care in a safe manner, resulting in two residents rolling out of bed during care and sustaining injuries. Resident #42, who was on blood thinner medication and had a history of falls, was being changed by a nurse aide who improperly turned her away from herself, causing the resident to slide off the bed. This resulted in skin tears on both arms and a hematoma on the left hip. The resident was cognitively intact and required assistance with transfers and activities of daily living. Despite the resident's initial reluctance, she was sent to the hospital for further evaluation. Resident #92, who had functional impairments and required substantial assistance for bed mobility, experienced a similar incident. During a bed sheet change, the nurse aide turned the resident away from herself, causing the resident to fall off the bed. The resident sustained a skin tear on the right arm but did not report any pain or head injury. The resident was cognitively intact and had not experienced any falls since the prior assessment. Both incidents highlight a failure in the facility's procedures for safely turning and repositioning residents. The nurse aides involved did not follow the standard practice of turning residents towards themselves, which could have prevented the falls. The facility did not complete a 100% audit or in-service training for all staff following these incidents, indicating a lack of comprehensive corrective action to prevent future occurrences.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of a resident to self-administer medications, leading to a deficiency. Resident #42, who was cognitively intact and had diagnoses including anemia, heart failure, hypertension, diabetes, and respiratory failure, was observed with two medication cups at her bedside. These medications were left by Nurse #2 without a physician's order for self-administration or an assessment of the resident's ability to self-administer medications. The resident was unsure which cup contained her regular medications and which contained vitamins, resulting in her not taking the medications. Nurse #2 admitted to leaving the medications on the bedside table when she was called to assist another resident, intending to return shortly but forgetting to do so. The Director of Nursing confirmed that medications should not be left at the bedside and should be administered by the nurse, ensuring the resident takes them before leaving the room. If the nurse needs to leave, the medications should be secured in the locked medication cart. This oversight in medication administration protocol led to the deficiency observed by the surveyors.
Failure to Provide SNF/ABN to Resident
Penalty
Summary
The facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) to a resident who was reviewed for beneficiary notices. The resident was admitted to the facility and began receiving Medicare Part A services on January 6, 2025, with the last covered day being January 19, 2025. Despite remaining in the facility after the discharge from Medicare Part A, there was no evidence that a SNF/ABN form was provided to the resident or their representative. During interviews, both the social worker and the administrator acknowledged that the SNF/ABN was missed and should have been provided to inform the resident or representative about the costs they would be responsible for out of pocket if they continued services no longer covered by insurance.
Failure to Address Pain Management in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing pain management for a resident who was admitted with a left leg fracture and was severely cognitively impaired. The resident was on a scheduled pain medication regime and experienced constant pain that affected sleep and daily activities, rating the pain as a 10 on a scale of zero to 10. Despite the Care Area Assessment (CAA) for pain being triggered, the comprehensive care plan initiated on 1/27/25 did not include a focus area for pain. Interviews with facility staff revealed that the MDS Director acknowledged the care plan should have been developed by 1/27/25, based on the comprehensive admission MDS assessment date of 1/14/25. The MDS Coordinator admitted to completing the assessment and recognized the oversight in not including the resident's pain in the care plan. The Director of Nursing also confirmed that the resident's pain should have been included in the comprehensive care plan.
Improper Application of Lidocaine Patch
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following a physician's order for the application of a lidocaine patch on a resident's left hip. Instead, the patch was applied to the resident's back. The resident, who was admitted with a left leg fracture and was severely cognitively impaired, experienced constant pain that affected his sleep and daily activities. The physician's order specifically directed the application of a 5% lidocaine patch to the resident's left hip, but documentation showed that Nurse #10 applied the patch to the resident's lower back without a corresponding physician's order. During an interview, Nurse #10 admitted to applying the patch to the resident's back after the resident requested it, despite knowing that a physician's order was required for such a change. The Director of Nursing and the resident's physician both confirmed that Nurse #10 should have obtained a physician's order before applying the patch to a different body part. The facility's administrator also acknowledged that the nurse acted outside of the physician's directive by applying the patch to the back without proper authorization.
Failure to Implement Diabetes Management Orders
Penalty
Summary
The facility failed to clarify and implement orders for blood sugar monitoring and insulin administration for a resident with diabetes following their discharge from the hospital. The hospital discharge summary for the resident included instructions to monitor blood sugars closely and to administer both short-acting and long-acting insulin. However, upon admission to the facility, these orders were not transcribed into the resident's medical record or Medication Administration Record (MAR), resulting in the resident not receiving necessary blood sugar monitoring or insulin administration since admission. The deficiency was identified when it was discovered that the admissions nurse overlooked the instructions for diabetes management in the discharge summary. The nurse admitted to not noticing the instructions and failing to contact the on-call physician or Nurse Practitioner for specific orders. The resident's physician was unaware of the need for these orders until informed later, at which point orders were written for blood sugar checks and insulin administration. The Director of Nursing noted that the admissions process was not followed correctly, as the admissions nurse signed off on the orders without a second nurse's review.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to attempt and document alternatives to bed rail use for a resident before installing them. The resident, who was admitted with a left leg fracture and diagnosed with severe cognitive impairment, had bed rails installed without a physician's order or documentation of alternative measures being considered. The resident's family member consented to the use of bed rails, believing they would assist with repositioning, but was not informed of any alternatives. Interviews with facility staff, including the Admissions Nurse and the Director of Nursing, revealed a lack of awareness and discussion regarding alternatives to bed rail use. The Admissions Nurse admitted to not discussing or attempting alternatives with residents or their families, and the Director of Nursing was unaware of any alternatives used by the facility. The Administrator also did not know what alternatives were attempted prior to the use of bed rails, indicating a systemic issue in the facility's approach to bed rail use.
Failure to Assess and Document Resident Food Preferences
Penalty
Summary
The facility failed to assess and document food preferences for a resident, leading to the provision of unwanted food items. A resident, who was moderately cognitively impaired, expressed dissatisfaction with receiving pork products, which she disliked, and stated that no one had inquired about her food preferences. Upon review, the Dietary Manager confirmed that there was no documentation of the resident's food preferences in the system and could not locate a paper assessment. The Dietary Manager mentioned that an assistant previously handled these assessments until two weeks prior. The Administrator expected the Kitchen Manager to ensure that food preference assessments were conducted upon admission, but this was not done for the resident in question.
Inaccurate MAR Documentation for Enteral Nutrition
Penalty
Summary
The facility failed to maintain a complete and accurate Medication Administration Record (MAR) for a resident who was receiving enteral nutrition. The resident, identified as Resident #333, had a physician's order for enteral formula Osmolite 1.5 to be administered every six hours. On one occasion, Nurse #4 began administering the formula, but the resident expressed a desire not to receive it, prompting the nurse to stop the administration. Despite this, the MAR inaccurately reflected that the midnight dose was given as prescribed. Interviews with other nursing staff, including Nurse #6 and Nurse #8, revealed that their practice would be to document any refusal of enteral formula on the MAR. The Director of Nursing and the Administrator both confirmed that refusals should be documented accurately, indicating that the administration was incomplete and the resident refused. The discrepancy in documentation suggests a failure to adhere to the facility's protocol for recording medication administration accurately.
Pest Control Deficiency Leads to Mouse Infestation in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mouse infestation that directly affected a resident. The resident, who was cognitively intact but had limited physical mobility due to a stroke, experienced multiple incidents where mice were found in her bed. These incidents occurred despite the facility having a contract with a pest control company that serviced the facility weekly. The pest control logs indicated that no mice were found during inspections, yet the resident reported seeing mice in her room and on her dresser. The facility's maintenance director acknowledged receiving reports of rodent activity shortly after construction began near the facility. However, there was a lack of clear communication and documentation regarding the reports of mice sightings. Staff members, including nurse aides and nurses, reported the presence of mice to each other, but there was no consistent follow-up or assessment of the resident involved. The maintenance director was unaware of mice being found in a resident's bed, and there was no log of where glue traps were placed or how many mice were caught. Interviews with staff and residents revealed that the facility had a problem with mice for several months, and the issue was linked to nearby construction. Despite efforts to address the problem, such as placing glue traps and rebaiting exterior bait stations, the facility's pest control measures were insufficient. The lack of effective communication and documentation, along with inadequate pest control measures, contributed to the deficiency, which posed a high likelihood of affecting other vulnerable residents in the facility.
Improper Urinary Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to maintain proper care for a resident with an indwelling urinary catheter, leading to a deficiency in infection control practices. The resident, who was admitted with obstructive and reflux uropathy, was observed with the urinary catheter drainage tubing lying on the floor beneath his wheelchair. This improper positioning of the tubing was noted during an observation, and it was confirmed that the tubing should not have been in contact with the floor as it posed an infection risk. The care plan for the resident included checking the catheter tubing for proper drainage and positioning, but this was not adhered to. Interviews with the nursing staff, including a nurse and two nursing assistants, revealed a lack of awareness and oversight regarding the catheter tubing's position. The nurse assigned to the resident was unaware of the tubing's contact with the floor, and the nursing assistants acknowledged that the tubing should not touch the floor due to infection concerns. The Director of Nursing confirmed that the tubing should have been secured properly to prevent contact with the floor and stated that staff received training on catheter care. However, the failure to ensure the tubing was off the floor was identified as a deficiency in the facility's infection control practices.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 60 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenville Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| East Carolina Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 14 | 0 |
| Cypress Glen Retirement Community | 4.1 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-farmville | 9.9 mi | ★★★★★ | 5 | 0 |
| Ayden Court Nursing And Rehabilitation Center | 10.1 mi | ★★★★★ | 6 | 1 |
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