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Deficiency Records for Mt Macrina Manor
A list of the most recent deficiencies for Mt Macrina Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Mt Macrina Manor. 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? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Meet other general requirements. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-08-20 | 2024-10-14 | 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 | 2024-08-20 | 2024-10-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-08-20 | 2024-10-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-20 | 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 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-18 | 2023-10-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Meet other general requirements. | Fire Safety | 2023-08-23 | 2023-10-06 | 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 | 2023-08-23 | 2023-10-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-23 | 2023-10-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-08-23 | 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 | 2023-08-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-04 | 2023-02-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-14 | 2022-12-28 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-11-14 | 2022-12-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-14 | 2022-12-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-09 | 2022-11-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-09 | 2022-11-03 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-09-09 | 2022-11-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-08 | 2022-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-08 | 2022-09-21 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-06-03 | 2022-07-21 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-06-03 | 2022-07-21 | Y |
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