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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-30 | 2024-01-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-30 | 2024-01-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-30 | 2024-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-30 | 2024-01-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-30 | 2024-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-05-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-29 | 2023-02-11 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-02-27 | 2020-04-01 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-27 | 2020-04-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-27 | 2020-04-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-02-27 | 2020-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-27 | 2020-04-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-27 | 2020-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-27 | 2020-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-27 | 2020-04-01 | 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 | 2020-02-27 | 2020-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-27 | 2020-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-27 | 2020-04-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-27 | 2020-04-01 | 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 | 2020-02-27 | 2020-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-27 | 2020-04-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-25 | 2020-04-01 | N |
| Have an externally vented heating system. | Fire Safety | 2020-02-25 | 2020-03-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-25 | 2020-03-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-25 | 2020-03-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-25 | 2020-03-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-15 | 2019-02-25 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-01-15 | 2019-01-30 | N |
