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

Chain footprint

21 facilities

Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.70

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

2.32

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.74

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

3.05

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.38

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.67

CMS adjusted RN staffing hours

Adjusted total hours

3.56

CMS adjusted total nurse staffing hours

Case-mix index

1.44

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,690

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

1.69

Composite VBP score used to determine payment impact.

Payment multiplier

0.9804

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 24.45% · Performance 25.06% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 7.31% · Performance 9.12% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

0

Performance 66.67% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.68

Baseline 3.06 hours · Performance 3.27 hours · Measure score 0.68 · Achievement 0.68 · Improvement 0.27

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.47%
10.72%
0.8 pts worse
No Different than the National Rate · Eligible stays 487 · Observed rate 10.88% · Lower 95% interval 9.25%
Discharge to community 58.91%
50.57%
8.3 pts better
Better than the National Rate · Eligible stays 527 · Observed rate 53.89% · Lower 95% interval 54.14%
Medicare spending per beneficiary 1.03
1.02
About the same
Drug regimen review with follow-up 99.18%
95.27%
3.9 pts better
Numerator 363 · Denominator 366
Falls with major injury 0.82%
0.77%
About the same
Numerator 3 · Denominator 366
Discharge self-care score 45.99%
53.69%
7.7 pts worse
Numerator 109 · Denominator 237
Discharge mobility score 21.94%
50.94%
29 pts worse
Numerator 52 · Denominator 237
Pressure ulcers or injuries, new or worsened 3.55%
2.29%
1.3 pts worse
Numerator 13 · Denominator 366 · Adjusted rate 4.12%
Healthcare-associated infections requiring hospitalization 9.12%
7.12%
2 pts worse
No Different than the National Rate · Eligible stays 342 · Observed rate 9.36% · Lower 95% interval 7.06%
Staff COVID-19 vaccination coverage 0.47%
8.2%
7.7 pts worse
Numerator 1 · Denominator 214
Staff flu vaccination coverage Not Available
42%
Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score 43.04%
56.45%
13.4 pts worse
Numerator 102 · Denominator 237
Transfer of health information to provider 94.85%
95.95%
1.1 pts worse
Numerator 129 · Denominator 136
Transfer of health information to patient 98.88%
96.28%
2.6 pts better
Numerator 177 · Denominator 179
Resident COVID-19 vaccinations up to date 9.09%
25.2%
16.1 pts worse
Numerator 15 · Denominator 165

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 · Adjusted 2.6 · Observed 3.1 · Expected 2.3 · Used in QM five-star
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 · Adjusted 2.0 · Observed 2.2 · Expected 1.9 · Used in QM five-star
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 · Q1 75.2% · Q2 86.1% · Q3 86.3% · Q4 84.4% · 4Q avg 83.0%
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 · 4Q avg 89.2%
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 · Q1 3.0% · Q2 2.0% · Q3 2.1% · Q4 3.1% · 4Q avg 2.5% · Used in QM five-star
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 · Q1 1.0% · Q2 4.9% · Q3 3.9% · Q4 1.2% · 4Q avg 2.6%
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 · Q1 12.8% · Q2 21.3% · Q3 8.8% · Q4 6.0% · 4Q avg 12.4%
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 · Q1 9.2% · Q2 12.4% · Q3 12.3% · Q4 8.2% · 4Q avg 10.5%
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 · Q1 12.2% · Q2 18.5% · Q3 13.4% · Q4 9.6% · 4Q avg 13.6% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · 4Q avg 18.6% · Used in QM five-star
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 · Q1 14.5% · Q2 5.8% · Q3 11.4% · Q4 6.2% · 4Q avg 9.5% · Used in QM five-star
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 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.5% · Used in QM five-star
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 · Q1 4.0% · Q2 3.0% · Q3 2.1% · Q4 1.1% · 4Q avg 2.6% · Used in QM five-star
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 · Q1 18.8% · Q2 16.9% · Q3 17.9% · Q4 11.7% · 4Q avg 16.3%
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 · Q1 2.7% · Q2 3.0% · Q3 4.8% · Q4 5.4% · 4Q avg 3.9% · Used in QM five-star
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 · Q1 40.0% · Q2 62.1% · Q3 79.0% · Q4 77.2% · 4Q avg 64.6%
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 · Adjusted 11.3% · Observed 11.8% · Expected 11.6% · Used in QM five-star
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 · Q1 2.0% · Q2 1.4% · Q3 3.0% · Q4 5.6% · 4Q avg 3.0% · Used in QM five-star
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 · 4Q avg 59.7%
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 · Adjusted 30.4% · Observed 32.6% · Expected 25.6% · Used in QM five-star

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

Nearby options

Other facilities in reach

#1

Greenville Health and Rehabilitation Center

Greenville, NC

1-star overall rating with 1-star inspections with $64,002 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

Overall
1 / 5
Health
1 / 5
Staffing
1 / 5
Fines
$64,002
#2

East Carolina Health and Rehabilitation Center

Greenville, NC

2-star overall rating with 2-star inspections with $66,765 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

Overall
2 / 5
Health
2 / 5
Staffing
3 / 5
Fines
$66,765
#3

Cypress Glen Retirement Community

Greenville, NC

5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle

Overall
5 / 5
Health
5 / 5
Staffing
5 / 5
Fines
$0

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