A list of the most recent deficiencies for Mitchell 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-07-26 | 2023-08-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-26 | 2023-08-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-09 | 2023-06-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-09 | 2023-06-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-09 | 2023-06-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-09 | 2023-06-01 | 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 | 2023-05-09 | 2023-06-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-09 | 2023-06-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-09 | 2023-06-01 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-22 | 2023-05-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-05-22 | 2023-05-31 | 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 | 2023-05-22 | 2023-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-22 | 2023-05-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-22 | 2023-05-31 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-26 | 2022-09-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-26 | 2022-09-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-15 | 2022-09-02 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-15 | 2022-09-02 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-15 | 2022-09-02 | Y |
| Meet other general requirements. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-12 | 2022-08-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-21 | 2022-07-14 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-21 | 2022-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-21 | 2022-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-21 | 2022-07-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-21 | 2022-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-21 | 2022-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-21 | 2022-07-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-30 | 2020-02-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-30 | 2020-02-24 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-01-30 | 2020-02-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-30 | 2020-02-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-06 | 2019-11-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-06 | 2019-11-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-06 | 2019-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-06 | 2019-11-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-06 | 2019-11-21 | N |
