Mitchell Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Mitchell Care & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578Mar 27, 2025

  Based on record review and interview, the facility failed to ensure residents were educated and offered the opportunity to create an advance directive for 4 (#16, 17, 56, and #58) of 5 sampled residents reviewed for advance directives. The administrator identified 57 residents who resided in the facility. Findings: 1. Resident #16 was admitted to the facility on [DATE]. A review of Resident #16's electronic health records showed no advance directive information had been provided. 2. Resident #17 was admitted to the facility on [DATE]. A review of Resident #17's electronic health records showed no advance directive information had been provided. 3. […]

• No harm, potential for more than minimal, patternF689Jan 16, 2025

  Based on observation, record review, and interview, the facility failed to ensure electrical outlets on both the East and [NAME] side hallways, nurses' stations, and living room areas had protective plates covering them. The administrator identified 60 residents resided in the facility. Findings: A Safe Homelike Environment policy, dated 04/28/2022, read in parts, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .'Environment' refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas .6. a. […]

• No harm, potential for more than minimal, patternF730Jul 23, 2024

  Based on record review and interview, the facility failed to complete nurse aide performance reviews at least yearly for 18 of 22 nurse aides employed by the facility. The administrator identified 22 full time nurse aides currently employed by the facility. Findings: An employee list documented 22 staff members currently working as certified nurse aides. On 07/22/24 at 3:17 p.m., the administrator provided documentation regarding a nurse aide skills performance checklist for four certified nurse aides currently working for the facility. On 07/22/24 at 4:00 p.m., the administrator stated only four of the 22 nurse aides currently working had a completed performance review. The administrator stated a previous employee had not completed the required task for all certified nurse aides.

• No harm, potential for more than minimal, patternF580Dec 29, 2022

  Based on record review and interview, the facility failed to notify the family of a change in condition on two (#1 and #2) of three residents reviewed. The Resident Census and Conditions of Residents, documented a census of 64 residents. Findings: A Condition Changes/Episodic policy, dated 04/12, read in part, Notify family and document . 1. Res #1 was admitted with diagnoses which included pseudobulbar affect, dementia and hypertension. A progress note, dated 08/20/22, documented Res has rash to abdomen, breast appears to have pustule and resident has been itching. A physician's order, dated 08/20/22, documented permethrin cream 5% (used to treat scabies), apply to entire body one time for rash. […]

• No harm, potential for more than minimal, isolatedF637Mar 27, 2025

  Based on record review and interview, the facility failed to ensure a significant change assessment was completed within 14 days of electing the hospice benefit for 1 (#60) of 1 sampled resident who was reviewed for hospice services. The administrator identified 57 residents resided in the facility. Findings: Resident #60 had diagnosis which included senile degeneration of the brain. A physician's order, dated 01/16/25, showed Resident #60 was admitted to hospice. Resident #60's quarterly assessment, dated 02/05/25, did not show hospice while a resident. A significant change assessment was not located in the residents electronic health record. On 03/25/25 at 9:43 a.m., the ADON stated Resident #60 was admitted to hospice services on 01/16/25. […]