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Deficiency Records for Mt Macrina Manor
View the most recent health deficiencies and inspection results for Mt Macrina Manor. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Mt Macrina Manor. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2026-01-29 | 2026-02-20 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2025-08-14 | 2025-10-01 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2025-08-14 | 2025-10-01 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-08-14 | 2025-10-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-08-14 | 2025-10-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2025-08-14 | 2025-10-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2025-08-14 | 2025-10-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-08-14 | 2025-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-08-14 | 2025-10-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-08-14 | 2025-10-01 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2025-08-14 | 2025-10-01 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2025-08-14 | 2025-10-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2025-08-14 | 2025-10-01 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2025-08-14 | 2025-10-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-08-30 | 2024-10-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-08-30 | 2024-10-14 | 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 | 2024-08-30 | 2024-10-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-18 | 2023-11-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-18 | 2023-10-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-18 | 2023-10-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-02-23 | N |