ElderGrade

Inspection citations at Mt Macrina Manor

18 citations on record, 0 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 0
2025 13 0
2024 1 0
2023 3 0
F January 29, 2026 Tag F0880 Complaint investigation Corrected Feb 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

B August 14, 2025 Tag F0949 Corrected Oct 2025

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

No actual harm, minimal potential

B August 14, 2025 Tag F0944 Corrected Oct 2025

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

No actual harm, minimal potential

B August 14, 2025 Tag F0942 Corrected Oct 2025

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

No actual harm, minimal potential

B August 14, 2025 Tag F0638 Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

No actual harm, minimal potential

B August 14, 2025 Tag F0636 Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

No actual harm, minimal potential

B August 14, 2025 Tag F0628 Corrected Oct 2025

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, minimal potential

C August 14, 2025 Tag F0941 Corrected Oct 2025

Administration Deficiencies

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

No actual harm, minimal potential

D August 14, 2025 Tag F0868 Corrected Oct 2025

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

No actual harm, potential for more than minimal harm

E August 14, 2025 Tag F0945 Corrected Oct 2025

Infection Control Deficiencies

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

No actual harm, potential for more than minimal harm

E August 14, 2025 Tag F0943 Corrected Oct 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

No actual harm, potential for more than minimal harm

F August 14, 2025 Tag F0881 Corrected Oct 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

F August 14, 2025 Tag F0880 Corrected Oct 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F August 14, 2025 Tag F0727 Corrected Oct 2025

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 30, 2024 Tag F0761 Corrected Oct 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 18, 2023 Tag F0698 Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D August 18, 2023 Tag F0689 Corrected Feb 2023

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

F August 18, 2023 Tag F0658 Corrected Nov 2023

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.