Mitchell Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF740Aug 15, 2022

  Based on interview and record review, the facility failed to implement appropriate interventions and monitoring for substance use disorder for 1 of 1 residents reviewed for substance use disorder. A resident with a history of [MEDICATION(S)] abuse and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in the resident requiring 2 doses of [MEDICATION(S)] (a medication used to treat an overdose of narcotics in an emergency situation) administration after he became unresponsive on 6/21/22. The resident was found with methamphetamines again on 8/9/22. This deficient practice resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF600Aug 26, 2022

  Based on interview and record review, the facility failed ensure a resident's right to be free from sexual abuse for 1 of 3 residents reviewed for sexual abuse. A cognitively intact male resident placed his hands down in the pants of a cognitively impaired female resident. (Resident C, Resident D) Finding includes: During an interview on 8/25/22 at 2:19 p.m., the Regional Director of Nursing indicated that CNA 1 reported Resident C had his hand in Resident D's pants. Resident D was cognitively impaired and would not have been able to consent. During an interview on 8/25/22 at 2:47 p.m., the SSD (Social Service Director) indicated on 8/19/22 at approximately 6:00 p.m., a CNA reported she saw Resident C with his hand down Resident D's pants. […]

• No harm, potential for more than minimal, patternF921May 1, 2026

  Based on observation and interview, the facility failed to provide a safe and sanitary environment for 1 of 4 hallways for 5 of 5 days during the survey. Strong urine odors were present. (Hallway B)Findings include: On 4/27/26 at 10:10 a.m., during the initial walkthrough of the facility a strong odor of urine was noted at the beginning of Hallway B. On 4/28/26 at 11:27 a.m., a strong urine odor was noted down Hallway B. On 4/29/26 at 8:47 a.m., a strong urine odor was noted down Hallway B. On 4/29/26 at 10:00 a.m., a strong urine odor was noted at entrance of Hallway B. There were multiple residents observed to be sitting in hall at this time. On 4/30/26 at 10:21 a.m., a strong urine odor was noted down Hallway B. […]

• No harm, potential for more than minimal, patternF602Dec 18, 2025

  Based on record review and interview, the facility failed to protect the residents right to be free from misappropriation of resident property for 7 out of 7 residents reviewed. The residents had money withdrawn from their accounts and placed in multiple other resident accounts. (Resident D, Resident E, Resident F, Resident G, Resident H, Resident J, and Resident K)Findings include:On 12/17/25 at 10:40 a.m., a facility incident report, dated 10/6/25, was provided by the Administrator. A review of the report indicated an allegation of possible misappropriation of funds in the resident trust account by the Business Office Manager (BOM).The report indicated on 10/6/25, the Administrator discovered a potential discrepancy involving the resident trust account. […]

• No harm, potential for more than minimal, patternF921Feb 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure the carpets were not worn and free of stains for 63 of 63 residents residing in the facility and failed to ensure a homelike environment for 2 of 16 residents reviewed for environment. (Hallway A, Hallway B, Hallway C, Hallway D, Resident 33 and Resident 16) Findings include: 1. On 2/24/25 at 11:00 a.m., during an initial tour, the carpet on Hallway A, Hallway B, Hallway C, and Hallway D were observed to be worn and to have multiple stains throughout. 2. On 2/26/25 at 10:02 a.m., a sign was observed to be on the wall in Resident 33's room which indicated to put dentures in denture cup before picking up meal tray or stray Kleenex. […]