Deficiency Records for Mitchell Manor

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Updated as of May 01, 2024

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Deficiency Records for Mitchell Manor

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.

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 special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-04-15 2024-04-24 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-04-15 2024-04-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-04-15 2024-04-24 N
Post nurse staffing information every day. Health 2024-03-25 2024-04-18 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-03-25 2024-04-18 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 2024-03-25 2024-04-18 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-03-25 2024-04-18 N
Provide and implement an infection prevention and control program. Health 2024-03-25 2024-04-18 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-03-25 2024-04-18 N
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

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