Mt Macrina Manor

Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for five of eight sampled residents (Residents R17, R20, R38, R58, and R90).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to ensure that resident's medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for one of eight residents (Resident R90).

Inspectors wroteBased on clinical record review, review of facility policy, and staff interview, it was determined the facility failed to ensure that a psychotropic (medications that affect mood, behavior, or mental processes) medication was used in accordance with regulatory requirements by failing to implement and document non-pharmacological interventions, failing to document any behaviors, and failing to ensure appropriate duration and rationale for a psychotropic medication order for one of eight residents reviewed (Resident R90).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility in a prominent place readily accessible to residents, staff, and visitors on four of four nursing units.

Inspectors wroteBased on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for seven of seven residents (Resident R1, R2, R3, R4, R5, R6, and R7) and two of three employees (Employee E1 and E2).

Inspectors wroteBased on observation, staff interviews, and Infection Control Preventionist (ICP) credential review, it was determined that in addition to the role of the Director of Nursing (DON), the DON was also the ICP since 6/18/25.

Inspectors wroteBased on observation, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of five residents reviewed (R13, R55, R96, and R112).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of twelve months (January 2025, and February 2025). Review of facility policy Antibiotic Stewardship Program reviewed 1/4/25, indicated the purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics to provide the best resident outcomes and to reduce the threat of antibiotic resistance by organisms. Review of the facility's Infection Control surveillance for September 2024 through July 2025, failed to include documentation to indicate that antibiotic monitoring was completed for January 2025 and February 2025. During an interview on 6/11/25, at 2:40 p.m. the Director of Nursing confirmed she was unable to locate the antibiotic monitoring for January 2025 and February 2025.

Inspectors wroteFindings include: Review of the Facility Assessment most recently reviewed July 2025, listed under the training topics Abuse, Neglect, and Exploitation. Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have Prevention of Abuse and Neglect in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have Prevention of Abuse and Neglect in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have Prevention of Abuse and Neglect in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have Prevention of Abuse and Neglect in-service education between 6/13/24, and 6/13/25. [...]

Inspectors wroteBased on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the Infection Control Program for two of ten staff members (Employees E3 and E4).

Inspectors wroteBased on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meetings (third quarter 11/20/24). Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 11/20/24, failed to reveal the Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems. During an interview on 8/12/25, at 2:20 p.m. [...]

Inspectors wroteBased on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for facility staff.

Inspectors wroteNumber of residents sampled:Number of residents cited:Findings Include:Review of facility policy, Bed Hold dated 1/4/25, indicated, Upon admission and when a resident is transferred for hospitalization or therapeutic leave, information will be provided concerning our bed-hold policy. When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed-hold policy within 24 hours of such transfer. Review of the clinical record indicated Resident R3 was readmitted to the facility on [DATE]. [...]

Inspectors wroteNumber of residents sampled:Number of residents cited:Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R15 had an admission date of 6/13/25, with an MDS completion date of 7/2/25. Resident R17 had an admission date of 5/19/25, with an MDS completion date of 6/19/25. Resident R27 had an admission date of 5/16/25, with an MDS completion date of 6/13/25. Resident R33 had an admission date of 7/10/25, with an MDS completion date of 7/25/25. [...]

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set (MDS- periodic review of resident care needs) assessments were completed within the required time frame for five of 20 residents (Residents R20, R34, R39, R42, and R43).

Inspectors wroteBased on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of ten staff members (Employees E1, E2, E3, and E4).

Inspectors wroteFindings include: Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have the QAPI Program in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have QAPI Program in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have QAPI Program in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have QAPI Program in-service education between 6/13/24, and 6/13/25. Licensed Practical Nurse Employee E5 had a hire date of 8/1/16, failed to have QAPI Program in-service education between 8/1/24, and 8/1/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on the QAPI Program for five of ten staff members. 28 Pa Code: [...]

Inspectors wroteBased on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of ten staff members (Employees E1 and E5).

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure medication in a medication cart in one of five medication carts reviewed (unused medication cart).