Greenville, NC

Macgregor Downs Health Center by Harborview

2-star overall rating with 2-star inspections with $10,023 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

2910 Macgregor Downs Road, Greenville, NC

(252) 758-4121

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

152

Certified beds

Average residents

137

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Harborview Health Systems

Operator or chain grouping

Approved since

1980-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.70

Registered nurse staffing

LPN hours / resident day

0.72

Licensed practical nurse staffing

Aide hours / resident day

2.32

Nurse aide staffing

Weekend hours

3.05

Weekend nurse staffing

RN turnover

57%

Annual RN turnover

Total nurse turnover

55%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.6
1.8
0.8 pts worse
1.9
0.7 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 2.0
1.8
0.2 pts worse
1.8
0.2 pts worse
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 83.0%
91.5%
8.5 pts worse
93.4%
10.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 89.2%
94.1%
4.9 pts worse
95.5%
6.3 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 2.5%
3.6%
1.1 pts better
3.3%
0.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 2.6%
4.8%
2.2 pts better
11.4%
8.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 12.4%
7.2%
5.2 pts worse
5.4%
7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 10.5%
21.6%
11.1 pts better
19.6%
9.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 13.6%
15.0%
1.4 pts better
16.7%
3.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.0%
About the same
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 18.6%
21.5%
2.9 pts better
16.3%
2.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 9.5%
16.8%
7.3 pts better
14.9%
5.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.5%
0.9%
0.4 pts better
1.0%
0.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 2.6%
2.6%
About the same
1.7%
0.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 16.3%
21.2%
4.9 pts better
19.8%
3.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 3.9%
6.0%
2.1 pts better
5.1%
1.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 64.6%
79.9%
15.3 pts worse
81.7%
17.1 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 11.3%
13.2%
1.9 pts better
12.0%
0.7 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 3.0%
1.5%
1.5 pts worse
1.6%
1.4 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 59.7%
78.1%
18.4 pts worse
79.7%
20 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 30.4%
22.9%
7.5 pts worse
23.9%
6.5 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-13 · Fire 2025-02-13

12 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-12-22 · Fire 2023-12-22

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 3 Health 2023-01-26 · Fire 2021-05-14

12 health deficiencies

Top issue: Administration (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-17

E · Potential for more than minimal harm 2025-02-13

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-04-17

E · Potential for more than minimal harm 2025-02-13

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-04-17

D · Potential for more than minimal harm 2025-02-13

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-04-17

D · Potential for more than minimal harm 2025-02-13

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-04-17

D · Potential for more than minimal harm 2025-02-13

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-04-17

F · Potential for more than minimal harm 2023-12-22

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-02-21

F · Potential for more than minimal harm 2023-12-22

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-02-21

F · Potential for more than minimal harm 2023-12-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-02-21

D · Potential for more than minimal harm 2023-12-22

K227 · Egress Deficiencies

Fire Safety

Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

Corrected 2024-02-21

D · Potential for more than minimal harm 2023-12-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-02-21

D · Potential for more than minimal harm 2023-12-22

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-02-21

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-13

E · Potential for more than minimal harm 2025-02-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2025-03-13

D · Potential for more than minimal harm 2025-02-13

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-03-13

B · Minimal harm 2025-02-13

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-03-13

K · Immediate jeopardy 2024-08-02

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-08-19

D · Potential for more than minimal harm 2024-08-02

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-08-19

E · Potential for more than minimal harm 2023-12-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-01-24

E · Potential for more than minimal harm 2023-12-22

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-01-24

D · Potential for more than minimal harm 2023-12-22

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-01-24

D · Potential for more than minimal harm 2023-12-22

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-01-24

D · Potential for more than minimal harm 2023-12-22

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-01-24

D · Potential for more than minimal harm 2023-12-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-01-24

D · Potential for more than minimal harm 2023-12-22

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-01-24

B · Minimal harm 2023-12-22

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-01-24

F · Potential for more than minimal harm 2023-01-26

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2023-02-22

E · Potential for more than minimal harm 2023-01-26

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2023-02-22

E · Potential for more than minimal harm 2023-01-26

F848 · Administration Deficiencies

Health

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2023-02-22

D · Potential for more than minimal harm 2023-01-26

F948 · Nursing and Physician Services Deficiencies

Health

Ensure that paid feeding assistants have the training they need.

Corrected 2023-02-22

B · Minimal harm 2023-01-26

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-02-22

Penalties and ownership

What sits behind the stars

$10,023 2024-08-02

Fine

Fine · fine $10,023

Fine

Ownership

Ga Nc 14, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 13 facilities 2022-03-01
Cl 2022 Irrv Tr

5% Or Greater Indirect Ownership Interest · Organization

50% 18 facilities 2022-03-01
De 2021 Irrv Tr

5% Or Greater Indirect Ownership Interest · Organization

50% 18 facilities 2022-03-01
Carlone, James

W-2 Managing Employee · Individual

0% 2 facilities 2022-03-01
Englander, David

Corporate Officer · Individual

0% 17 facilities 2022-03-01
Leibowitz, Chaim

Corporate Officer · Individual

0% 22 facilities 2022-03-01

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