Deficiency Records for Mitchell Manor
Updated as of July 01, 2022
This is not the most recent data for Mitchell Manor. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2020-08-13 | 2020-08-24 | Y |
| 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 |
| Meet other general requirements. | Fire Safety | 2018-12-19 | 2019-01-18 | 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 | 2018-12-19 | 2019-01-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-12-19 | 2019-01-18 | 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 | 2018-12-19 | 2019-01-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-19 | 2019-01-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-30 | 2018-12-30 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2018-11-30 | 2018-12-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-30 | 2018-12-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-30 | 2018-12-30 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-11-30 | 2018-12-30 | N |
| Provide activities to meet all resident's needs. | Health | 2018-11-30 | 2018-12-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-30 | 2018-12-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-11-30 | 2018-12-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-30 | 2018-12-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Develop a communication plan. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2017-12-11 | 2018-01-10 | 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 | 2017-12-11 | 2018-01-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-12-11 | 2018-01-10 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-11-03 | 2017-11-22 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-11-03 | 2017-11-22 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-03 | 2017-11-22 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-11-03 | 2017-11-22 | N |
