Aria at Mitchell Manor

In the surveyor’s words

From the most serious findings on record at Aria at Mitchell Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Oct 16, 2023

  Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R39) of 3 Residents reviewed for pressure injuries. The facility did not routinely assess R39's skin condition, did not implement or update care plans in response to skin changes, and did not evaluate the effectiveness of current care planned interventions and implement effective and timely interventions to prevent R39's pressure injury from becoming an infected stage 4 pressure injury that led to two weeks of hospitalization . […]

• Actual harm, isolatedF686Sep 9, 2021

  Based on interview and record review, the facility did not provide necessary treatment and services to promote healing for a pressure injury. This was observed with 1 (R3) of 3 residents reviewed for pressure injuries. * R3 had an unstageable pressure injury to the left heel and left toe as well as a deep tissue injury to the left lateral foot. R3 had a left below the knee amputation on 8/3/21. The facility was not consistently assessing R3's pressure injury on a weekly basis to determine any changes or infections. The comprehensive care plan did not include interventions upon admission to prevent pressure injuries and was not updated per Facility policy. There was no change in treatment or interventions to advance healing prior to amputation. […]

• Actual harm, isolatedF578Apr 14, 2021

  Based on record review and staff interviews the facility did not always ensure that they had a system in place to ensure a residents advance directives were maintained and accurately documented in the resident's medical record for 2 of 13 sampled residents (R94 & R14) R94's wishes were to be a Do Not Resuscitate code status. R94 experienced a significant decline in condition and was being transported by Emergency Medical Staff to the hospital. The EMS staff did not have the necessary advanced directive paper work for R94 and CPR was provided against R94's wishes. […]

• Actual harm, isolatedF692Apr 14, 2021

  Based on observations, record review and staff interviews the facility did not always ensure that they recognized, evaluated and addressed the needs of 5 out of 7 residents (R30, R32, R4, R6 & R2) who were identified to be at risk or already experiencing impaired nutritional statuses. The facility did not always consistently obtained weights on these residents to identify significant weight loss and then develop interventions based on a comprehensive nutritional status - R30 was noted on 1/28/21 to have experienced a 16 pound weight loss over a 5 month period of (-11.7%) change in weight. Weekly weights and monitoring of meal intake were no implemented following the weight loss. On 4/14/21 R30 was reweighed for the first time since 2/24/21 and was noted to be at 110.4 pounds. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2026

  Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for two kitchen refrigerators this has the potential to affect all 45 Residents residing in the facility. *Temperature logs were not up to date for two refrigerators in the kitchen.Findings include:The Facility Policy and Procedure Manual titled Food Storage, dated 2019, documents in part:Procedure.12. Refrigerated food storage.b. TCS (Time and Temperature Control for Safety) foods must be maintained at or below 41 degrees F (Fahrenheit) unless otherwise specified by law. […]