Deficiency Records for Macgregor Downs Health Center By Harborview
Updated as of March 01, 2024
A list of the most recent deficiencies for Macgregor Downs Health Center By Harborview. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-17 | 2024-02-21 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2024-01-17 | 2024-02-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-17 | 2024-02-21 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-17 | 2024-02-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-17 | 2024-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-17 | 2024-02-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-22 | 2024-01-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-22 | 2024-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-22 | 2024-01-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-22 | 2024-01-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-22 | 2024-01-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-22 | 2024-01-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-22 | 2024-01-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-22 | 2024-01-24 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-26 | 2023-02-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-26 | 2023-02-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-26 | 2023-02-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-01-26 | 2023-02-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-26 | 2023-02-22 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-01-26 | 2023-02-22 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-01-26 | 2023-02-22 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-01-26 | 2023-02-22 | N |
| Ensure that paid feeding assistants have the training they need. | Health | 2023-01-26 | 2023-02-22 | N |
| 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. | Health | 2023-01-26 | 2023-02-22 | Y |
| 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. | Health | 2023-01-26 | 2023-02-22 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-26 | 2023-02-22 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-14 | 2021-06-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-14 | 2021-06-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-14 | 2021-06-11 | N |
| 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. | Health | 2021-05-14 | 2021-06-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-14 | 2021-06-11 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-05-14 | 2021-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-14 | 2021-06-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-14 | 2021-06-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-14 | 2021-06-11 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-03-22 | 2021-05-14 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-03-22 | 2021-05-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-22 | 2021-05-14 | Y |
