Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mitchell Manor during CMS and state inspections, most recent first.
Strong urine odor in Hallway B. Surveyors repeatedly observed a noticeable urine smell at the beginning of and down Hallway B, including near the entrance where multiple residents were sitting in the hall. CNA 1 and CNA 2 both confirmed the odor, and the DON acknowledged the facility was aware of the strong smell at the entrance of Hallway B and cited the facility policy that residents have the right to a clean and comfortable environment.
Inaccurate MDS coding affected two residents. One resident’s PASARR Level II status was coded inconsistently with the record, and another resident’s MDS failed to code an antidepressant on Item N0415 even though the resident was receiving Trazodone for insomnia and had diagnoses including schizoaffective disorder, major depressive disorder, and anxiety.
A resident who smoked and had COPD, paranoid schizophrenia, and mild neurocognitive disorder was observed smoking during designated smoking times with staff supervision, but the clinical record lacked a smoking care plan. The MDS and progress notes identified the resident as a smoker, and the DON confirmed that a smoking assessment and individualized smoking care plan should have been completed for the resident.
A Business Office Manager misappropriated resident funds by making unauthorized withdrawals and transferring money between resident accounts without proper documentation or authorization. Multiple residents were affected, with funds missing or moved to cover up cash payments that were not deposited. Audits revealed numerous undocumented transactions, and the misappropriation was confirmed through interviews and record reviews.
A resident with a history of behavioral and medical issues became verbally aggressive after a change in pain medication. During the incident, an LPN who was not assigned to the resident engaged in a verbal altercation, exchanging profanities and inappropriate remarks with the resident. The staff did not follow the resident's care plan interventions for de-escalation, resulting in a failure to protect the resident from verbal abuse.
A resident with multiple complex medical conditions experienced significant, unaddressed weight loss due to inconsistent monitoring, gaps in documentation, and delays in implementing dietary interventions. Despite being at risk for nutritional problems, the resident's fluctuating weights were not consistently verified or acted upon, and staff interviews revealed a lack of awareness regarding the weight loss. The facility did not follow its own policy for monitoring new admissions, resulting in prolonged periods without appropriate nutritional support.
A resident with COPD and depression was left unattended in a facility van for about 15 minutes while the transportation staff exited to deliver lunch to his wife at a hospital. The van's air conditioning was off and the window was rolled down. The resident eventually left the vehicle to seek help, and a hospital security guard assisted until the staff returned. The incident was not documented in the clinical record and was reported by the resident over a week later, indicating a failure to provide adequate supervision during transport.
The facility failed to maintain a homelike environment, with worn and stained carpets in multiple hallways affecting all residents. Additionally, signs with private information were found in two residents' rooms, indicating a lack of privacy and comfort. The DON acknowledged the need for carpet replacement and sign removal.
A facility failed to complete the Discharge MDS assessment within the required timeframe for a resident with Alzheimer's, anxiety, and major depressive disorder. The resident was discharged to another facility, but the Discharge MDS was not completed, with the last assessment being a Quarterly MDS. The MDS nurse confirmed the oversight and noted the lack of a resident assessment policy, relying on RAI tool criteria for timeframes.
The facility failed to accurately assess active diagnoses for two residents. One resident's MDS assessment did not reflect a recent UTI diagnosis, despite lab results and treatment indicating otherwise. Another resident's assessment failed to mark bipolar disorder as active, despite an active medication order for the condition. The MDS nurse confirmed these oversights, noting the absence of a formal MDS policy.
The facility failed to document the shower preferences of two residents in their care plans. One resident preferred showers on specific days, while another preferred evening showers. Despite these preferences being noted in their ADL forms, they were not updated in the care plans, as confirmed by the MDS nurse and DON. The facility's policy requires care plans to be developed within seven days after the comprehensive assessment, which was not followed.
Strong urine odor in Hallway B
Penalty
Summary
The facility failed to provide a safe and sanitary environment in Hallway B, where a strong urine odor was repeatedly observed during the survey. On 4/27/26, 4/28/26, 4/29/26, 4/30/26, and 5/1/26, surveyors noted a strong urine smell at the beginning of or down Hallway B, including at the entrance where multiple residents were observed sitting in the hall. During interviews, CNA 1 and CNA 2 both acknowledged a noticeable urine odor in Hallway B, and the DON stated the facility was aware of a strong odor at the entrance of Hallway B and confirmed the facility policy that all residents have the right to a clean and comfortable environment.
Inaccurate MDS Coding for PASARR Status and Antidepressant Use
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessment for 2 of 24 residents reviewed for MDS accuracy. For Resident 64, the clinical record showed diagnoses including anxiety and bipolar disorder, and a PASARR dated 5/8/23 indicated a Level II screening. However, the annual MDS assessment dated 1/30/26 stated the resident was not currently considered by the State to have a Level II PASARR screening, which was inconsistent with the PASARR information in the record. For Resident 9, the clinical record included diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. A physician order dated 6/26/25 showed Trazodone HCl 25 mg by mouth at bedtime for insomnia, but the quarterly MDS assessment dated 2/18/26 did not indicate the resident received an antidepressant medication on Item N0415. The RAI Manual stated medications are to be coded in Item N0415 according to therapeutic category and/or pharmacological classification, and the MDS Coordinator acknowledged the resident was taking an antidepressant at the time of the assessment and that Item N0415C1 should have been coded yes.
Missing Smoking Care Plan for Resident Who Smoked
Penalty
Summary
The facility failed to ensure a comprehensive plan of care was created for a resident who was a smoker, and failed to ensure appropriate supervision and interventions were in place to prevent the potential for accidents for 1 of 4 residents reviewed for accidents. Resident 55 was observed smoking during the designated smoking time with staff supervision on 4/28/26, 4/29/26, and 4/30/26. The resident’s record showed diagnoses of COPD, paranoid schizophrenia, and mild neurocognitive disorder. The admission MDS dated 10/20/25 indicated the resident was a smoker, and progress notes showed the resident was a smoker on admission and continued to smoke through the present. The resident’s clinical record lacked a care plan for smoking. During interview, the resident confirmed he was a current smoker and had smoked since admission. The DON stated that a smoking assessment should be completed on admission and quarterly for each resident who smokes, and that any resident who smokes should have a care plan implemented on admission. The DON also confirmed there was no smoking-related care plan for Resident 55. Facility policy required that all residents who smoke have a smoking assessment completed with appropriate care plan interventions documented, and that the IDT develop an individualized smoking care plan including smoking safety/assistance and education of the smoking policy and level of understanding.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically resident funds, as evidenced by unauthorized withdrawals and transfers between resident accounts. The Business Office Manager (BOM) was responsible for managing the Resident Funds Management System (RFMS), which maintained individual accounts for each resident. An incident was discovered when the Administrator identified discrepancies in the resident trust account, prompting an internal investigation. The investigation revealed that the BOM had made unauthorized withdrawals from the accounts of seven residents and transferred these funds into the accounts of other residents without proper authorization or documentation. Audit records showed multiple instances where funds were withdrawn from specific residents and deposited into other residents' accounts, with amounts and batch numbers detailed in the audit sheet. Additionally, the audit of the RFMS Petty Cash fund indicated 100 transactions from February 2023 through September 2025 that lacked verification tickets or resident/resident representative signatures, all completed by the BOM. The Administrator and Regional Field Controller confirmed that the BOM had accepted cash payments from residents or their representatives but failed to deposit the cash into the trust account, instead covering the missing funds by moving money from other resident accounts. During interviews, the BOM admitted to taking resident money but did not provide full details or documentation regarding the missing funds. The Administrator and Regional Field Controller verified that the misappropriation occurred over an extended period, with the BOM manipulating accounts to conceal the missing funds. The facility's policy on abuse prevention, which prohibits misappropriation of resident property, was not followed in these instances, resulting in the substantiated deficiency.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with a history of multiple rib fractures, right tibia fracture, antisocial personality disorder, and seizures was subjected to verbal abuse by a staff member. The resident, who had been at the facility for four months, became agitated and verbally aggressive after a reduction in his pain medication. Multiple staff interviews confirmed that the resident was yelling and cursing at the nursing station, demanding to speak with management. During this episode, an LPN who was not assigned to the resident approached and engaged in a verbal altercation with him. Both the resident and the LPN exchanged profanities and inappropriate remarks, escalating the situation rather than de-escalating it as outlined in the resident's care plan. The care plan for the resident specifically included interventions for managing verbally aggressive behavior, such as analyzing triggers, allowing the resident to express feelings, and staff walking away if the resident became aggressive. However, these interventions were not followed during the incident. Instead, the LPN confronted the resident and participated in the exchange of abusive language. This failure to adhere to the care plan and facility policy resulted in the resident not being protected from verbal abuse by staff.
Failure to Monitor and Address Significant Weight Loss in a Resident
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and address the nutritional status of a resident with significant weight loss. The resident, who had multiple diagnoses including dementia, Parkinson's disease, chronic kidney disease, muscle weakness, and dysphagia, was identified as being at risk for nutritional problems. Despite this, there were inconsistencies and gaps in the documentation of the resident's weights, with several periods lacking recorded weights or care management notes. Notably, there were significant fluctuations in the resident's recorded weights, including a drop from 178 pounds to 166.9 pounds within a month, and later a drastic decrease to 103.6 pounds, with some weights suspected to be inaccurate but not verified or clarified in the record. The care plan and dietary notes indicated that the resident was to be monitored for weight changes and provided with appropriate dietary interventions. However, the clinical record lacked timely documentation of interventions in response to the resident's weight loss, such as the initiation of supplements or changes in diet. There were also delays in updating care plans and implementing interventions like health shakes and fortified foods, with orders for supplements not being entered into the electronic health record until much later, despite being dated earlier. The interdisciplinary team did not consistently document reassessment or adjustment of interventions in response to ongoing weight loss. Interviews with staff revealed a lack of awareness regarding the resident's weight loss, and the facility's policy for monitoring new admissions was not consistently followed. The resident required assistance with eating, but this need was not always reflected in the care documentation. The failure to consistently monitor, document, and intervene in the resident's nutritional status led to unaddressed and significant weight loss over several months.
Resident Left Unsupervised in Facility Van During Transport
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic obstructive pulmonary disease and depression was left unsupervised in the facility transportation van during a scheduled doctor's appointment. The staff member responsible for transportation admitted to leaving the resident alone in the vehicle with the window rolled down while he delivered lunch to his wife at a nearby hospital. The van's air conditioning was turned off, and the resident remained unattended for approximately 15 minutes. During this time, the resident exited the vehicle and entered the hospital to locate the driver, where a security guard provided assistance until the driver returned. The clinical record lacked documentation of the incident, and the event was not reported by the resident until over a week later. The facility's policy on transportation coordination and services required adherence to safety procedures, but these were not followed in this instance. The average high temperature during the week of the incident was 90 degrees, and the resident was not available for interview during the survey period. The deficiency was identified through interviews and record review, revealing a failure to provide adequate supervision and ensure the area was free from accident hazards during resident transport.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents. During an initial tour, the carpets in Hallways A, B, C, and D were observed to be worn and stained, affecting all 63 residents residing in the facility. Additionally, signs containing private information were found in the rooms of two residents. In Resident 33's room, a sign instructed to place dentures in a cup before picking up meal trays or stray Kleenex. In Resident 16's room, a sign displayed his turning schedule from 8 a.m. to 6 p.m. These signs were still present days later, indicating a failure to ensure a homelike environment. The Director of Nursing acknowledged the need for carpet replacement and the removal of the signs, as they contained private information meant for staff convenience only.
Failure to Complete Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to complete the Discharge Minimum Data Set (MDS) assessment within the required timeframe for one resident. Resident 48, who had diagnoses including Alzheimer's disease, anxiety, and major depressive disorder, was discharged to another facility on 10/1/24. However, the Discharge MDS assessment was not completed, with the last recorded assessment being a Quarterly MDS Assessment on 9/10/24. According to the Resident Assessment Instrument (RAI) Version 3.0 User's Manual, the Discharge MDS assessment should have been completed within 14 calendar days of the discharge date. During an interview, the MDS nurse confirmed that the assessment was not completed as required and acknowledged the absence of a resident assessment policy, relying instead on the RAI tool criteria for completion timeframes.
Inaccurate Resident Assessments for Active Diagnoses
Penalty
Summary
The facility failed to ensure accurate assessments of active diagnoses for two residents. For Resident 20, the clinical record review revealed a diagnosis of Parkinson's disease, dementia, and benign prostatic hyperplasia. However, the Quarterly MDS assessment did not reflect a recent diagnosis of a urinary tract infection (UTI), despite laboratory results indicating the presence of Aerococcus urinae and the administration of Ceftriaxone Sodium for a UTI. The MDS nurse confirmed that the assessment should have marked the UTI as an active diagnosis, acknowledging the oversight and the absence of a specific MDS policy at the facility. Similarly, for Resident 57, the Admission MDS assessment failed to mark bipolar disorder as an active diagnosis, even though the resident had an active medication order for Depakote to treat bipolar disorder. The MDS nurse confirmed that the resident had an active diagnosis of bipolar disorder at the time of the assessment, which was incorrectly marked. The facility relied on the RAI tool for MDS assessments but lacked a formal MDS policy, contributing to these inaccuracies.
Failure to Document Resident Preferences in Care Plans
Penalty
Summary
The facility failed to develop and document care plans for the preferences of two residents regarding their shower schedules. Resident 24 expressed a preference for showers on Tuesdays and Fridays, which was noted in her Activities of Daily Living (ADL) Preferences form dated 12/30/24. However, this preference was not updated in her care plan. The Admission Minimum Data Set (MDS) assessment indicated that it was very important for Resident 24 to choose her bathing method, yet the care plan did not reflect this preference. Interviews with the MDS nurse and the Director of Nursing (DON) confirmed the absence of a care plan for Resident 24's preferences. Similarly, Resident 49 indicated a preference for evening showers, although she had no specific preference for the days. This preference was documented in her ADL Preferences form dated 1/2/25, but it was not updated in her care plan. The Admission MDS assessment noted that it was not very important for Resident 49 to choose her bathing method, yet a care plan should have been developed. The MDS nurse and the DON confirmed that Resident 49's care plan lacked documentation of her preferences. The facility's policy requires care plans to be developed within seven days after the comprehensive assessment, which was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mitchell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White River Lodge | 7.7 mi | ★★★★★ | 15 | 0 |
| Stonebridge Health Campus | 8.3 mi | ★★★★★ | 4 | 0 |
| Majestic Care Of Bedford | 8.9 mi | ★★★★★ | 10 | 0 |
| Westview Nursing And Rehabilitation Center | 9.6 mi | ★★★★★ | 3 | 0 |
| Core Of Bedford | 10.3 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.