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01
The Essentials
Summary
Across 5 inspections from August 2024 to August 2026, state surveyors documented 20 findings at Mt Macrina Manor; 20 have a recorded correction; CMS lists 1 enforcement action in the window.
Inspections
5
2024–2026, complaint and standard
Findings
20
Deficiencies cited by state inspectors
Corrected
20
Of 20 findings, with a recorded correction date
Penalties
1
1 fine; payment not published
Findings by Year
Findings
Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
Findings by year
Year
Inspections
Findings
Of which, actual harm (level G or above)
2024
1
1
0
2025
1
13
0
2026
3
6
1
What the Record Shows
20 of 20 findings have a recorded correction date.
CMS lists 1 enforcement action in the window: 1 fine of $13,070, its payment not published.
2 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, July 30, 2026, recorded 4 findings (most serious: Level E).
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
2026
Complaint investigation
1 finding
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Aug 10, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2026
Standard health inspection
4 findings
F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Aug 18, 2026
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Aug 18, 2026
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Aug 18, 2026
F732Post nurse staffing information every day.Level BPotential for minimal harmCorrected Aug 18, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2026
Complaint investigation
1 finding
F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 20, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2025
Standard health inspection
13 findings
F727Have 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.Level FNo actual harm, potential for moreCorrected Oct 1, 2025
F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 1, 2025
F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Oct 1, 2025
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level ENo actual harm, potential for moreCorrected Oct 1, 2025
F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Level ENo actual harm, potential for moreCorrected Oct 1, 2025
F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Oct 1, 2025
F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level CPotential for minimal harmCorrected Oct 1, 2025
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level BPotential for minimal harmCorrected Oct 1, 2025
F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level BPotential for minimal harmCorrected Oct 1, 2025
F638Assure that each resident’s assessment is updated at least once every 3 months.Level BPotential for minimal harmCorrected Oct 1, 2025
F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level BPotential for minimal harmCorrected Oct 1, 2025
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level BPotential for minimal harmCorrected Oct 1, 2025
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level BPotential for minimal harmCorrected Oct 1, 2025
Enforcement Action
Civil money penalty, $13,070 imposed July 21, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 14, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2024
Standard health inspection
1 finding
F761Ensure 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.Level DNo actual harm, potential for moreCorrected Oct 1, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
03
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
1
Infection Control, Cited in Two Inspections
Inspectors cited F880 in August 2025 and January 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2425262626F880 across all 5 inspections, oldest to newest
04
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
01
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level F.
02
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
03
What led to the 2026 fine, and has it been paid?
A $13,070 civil money penalty was imposed July 21, 2026. CMS publishes the fine, not whether it has been paid.
05
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Pennsylvania state survey agency.
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Pennsylvania state survey agency
Inspection Aug 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Pennsylvania state survey agency
Inspection Aug 14, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Pennsylvania state survey agency
Inspection Jan 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Pennsylvania state survey agency
Inspection Jul 30, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Pennsylvania state survey agency
Inspection Aug 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
CMS publishes about three inspection cycles; inspections before August 2024 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
Complaints not investigated onsite
Allegations screened out by the state before an onsite visit are not published.
Complaint allegations
CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents
Self-reported incidents appear only if they led to an inspection.
Follow-up visits
CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections
Published by CMS separately and not included in this record yet.
Staffing levels and ownership history
Published by CMS separately and not included in this record.
Whether fines were paid
CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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