Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Aria At Mitchell Manor during CMS and state inspections, most recent first.
A resident’s representative twice reported to the Director of Care Transitions that staff were frustrated with the resident’s frequent call light use, allegedly yelled at and called the resident names, and that a CNA, described as agitated and aggressive, roughly repositioned the resident in bed, which the representative believed resulted in left 7th and 8th rib fractures and subsequent hospital transfer. The facility’s grievance log contained no entries for these concerns, the Director of Care Transitions did not document or retain any record of the reports or forwarding them to the DON or Administrator, and the DON, although she discussed the rib fractures with the representative and reviewed the chart, did not treat the concerns as a grievance or allegation of abuse requiring investigation, contrary to the facility’s grievance policy.
A resident with multiple fractures, osteoporosis, and significant comorbidities experienced severe left rib pain while being repositioned by a CNA, was assessed by nursing, and was sent to the ER where imaging showed new anterior rib fractures in addition to old fractures. The facility’s policy required immediate (within 2 hours) reporting of any allegation of abuse or incident resulting in serious bodily injury, and reporting of other incidents within 24 hours, to regulatory agencies. The resident’s representative later reported that the CNA had been extremely agitated about the call light, allegedly grabbed the resident around the torso, and yanked her backward in bed, which the representative believed caused the fractures, and raised concerns about how this could occur when repositioning had been done previously without incident. The DON spoke with the CNA, who reported hearing a “crack” during repositioning, and with the representative, but the DON and Administrator concluded that, due to the resident’s history of fractures and comorbidities, there was no need to treat the event or the representative’s concerns as an allegation of abuse or neglect, and they did not report the incident to the State Survey Agency.
A resident with multiple fractures, osteoporosis, and significant comorbidities required 1-person assistance and scheduled repositioning in bed. During staff-assisted repositioning, the resident experienced severe left rib pain, and imaging later showed new anterior rib fractures in the context of multiple old fractures. The resident’s representative reported that a CNA had entered the room agitated about call light use and allegedly grabbed the resident around the torso and yanked her backward in bed, raising concerns of possible mistreatment. Despite a facility policy requiring comprehensive internal investigations of such incidents, the DON relied on the resident’s fragility and physician input to conclude no investigation was needed, interviewed only the involved CNA, and did not interview other staff or residents or otherwise conduct the minimum investigative steps outlined in the abuse prevention program.
Surveyors found that the facility did not maintain a clean and homelike environment on one floor, with dirty, stained carpets, persistent urine odor, debris and dead insects in light fixtures, and unclean fans in the dining area. The elevator area was also dirty and obstructed by food particles. Staff interviews revealed no established cleaning schedules or documentation for these areas, and cleaning was only performed when issues were noticed or reported.
The facility failed to maintain an effective infection control program, lacking a comprehensive water management plan and proper PPE usage for a resident on droplet precautions. The 2nd floor closed unit was poorly maintained, with no documentation of regular flushing or risk assessment. Staff did not consistently wear required PPE, such as masks and eye protection, for a resident with pneumonia, indicating significant lapses in infection control practices.
The facility failed to provide written transfer notices to five residents or their representatives when they were hospitalized due to changes in condition. Despite the facility's policy requiring written notification, evidence of such notices was lacking, and verbal communication was sometimes used without proper documentation. This deficiency was noted by surveyors, and the facility was unable to provide further documentation.
The facility did not ensure timely administration of pneumococcal and influenza vaccines to two residents. One resident did not receive the pneumococcal vaccine as requested, and another did not receive the influenza vaccine for the current season. The facility's policy requires offering these immunizations unless contraindicated or already given, but delays occurred due to the pharmacy's scheduling practices.
A resident did not receive medications as prescribed due to the facility's failure to have the correct doses available. The resident was given a lower dose of folic acid than ordered, and Disulfram was not administered because it was not available. Staff interviews confirmed these issues, highlighting a failure to adhere to the facility's medication policy.
The facility failed to prevent accident hazards and implement fall interventions, affecting all residents on a unit. Insulin and blood glucose medications were left unattended, violating policy. A resident with severe cognitive impairment did not have fall interventions consistently in place, such as a body pillow and soft touch call light, despite being at high risk for falls. Staff interviews confirmed non-compliance with care plans.
Failure to Document and Investigate Resident Grievances Related to Alleged Rough Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to address care concerns raised by a resident’s representative. The facility’s written grievance policy, revised 2/12/25, requires that when a grievance is noted verbally or in writing, staff attempt to resolve the issue or direct the complainant to appropriate leadership, notify the Grievance Officer, record identifying information and the nature of the matter, route the grievance for investigation, and ensure efforts toward resolution within seven days, including verbal follow-up to the resident. Surveyor review of the grievance log on 2/3/26 showed no documented concerns from the resident or the resident’s representative, despite allegations that concerns had been reported to facility staff. According to the report, the resident’s representative contacted the Director of Care Transitions on two occasions to report concerns about the resident’s care. After care provided on 11/13/25, the representative reported on 11/14/25 that staff became very frustrated when the resident needed frequent adjustments in bed, called the resident names, and yelled at the resident for using the call light and “wasting” staff time by calling so often. Later, following care on 12/22/25, the representative again contacted the Director of Care Transitions on 12/23/25, alleging that a CNA entered the resident’s room extremely agitated and aggressive about the resident having pushed the call light, then came behind the resident, grabbed the resident around the torso, and yanked the resident backward in bed, which the representative stated resulted in fractures to the resident’s left 7th and 8th ribs. The representative reported to the State Survey Agency that they were not aware of any action taken after the first incident and that the resident was transported to the hospital the day after the second incident. During interviews, the Director of Care Transitions acknowledged remembering conversations with the resident’s representative but did not recall the details, did not take notes, and stated he did not work inside the buildings or know the grievance process, and that he would typically forward an email to the DON or Administrator. He had no documentation in his phone or email showing that he communicated these concerns. The DON stated she had spoken with the representative about the 12/22/25 incident, reviewed the resident’s medical chart, and understood the representative wanted to know how the rib fractures occurred, but she did not consider the questions to be an allegation of abuse or a grievance to address, despite the representative’s concern that the CNA’s hurried and angry repositioning could have caused the fractures. The Administrator later acknowledged that the concerns brought forth by the representative should have been handled as a formal grievance and investigated, but no grievance entry, investigation, or documented resolution was found for these concerns.
Failure to Report Alleged Abuse and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of possible abuse or mistreatment to the State Survey Agency as required by regulation and by its own Abuse Prevention Program policy. The policy states that any allegation of abuse or any incident resulting in serious bodily injury must be reported to required regulatory agencies immediately, but not more than two hours after the allegation, and that other reportable incidents must be reported within 24 hours. Despite this, the facility did not report an incident in which a resident developed new rib fractures associated with staff repositioning, nor did it report subsequent concerns raised by the resident’s representative that the CNA had been angry and aggressive during care. The resident involved had multiple significant comorbidities, including a left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, sacral pressure ulcer, GERD, repeated falls, osteoporosis, and a history of multiple fractures, including rib fractures. The care plan and physician orders required Q2–3 hour repositioning with a wedge and assistance of one staff for bed mobility and transfers. On the date of the incident, while being repositioned in bed by a CNA, the resident complained of severe sharp, stabbing pain in the left ribs, with pain on palpation. A nurse assessed the resident, administered PRN Tramadol without effective relief, and the resident was sent to the ER, where imaging showed suspected new fractures of the left 7th and 8th anterior ribs along with old bilateral rib fractures and thoracic compression fractures. Following the incident, the resident’s representative reported to facility leadership that the CNA had entered the room extremely agitated and aggressive about the call light, and that the CNA allegedly grabbed the resident around the torso from behind and yanked her backward in bed, which the representative believed caused the rib fractures. The representative also reported these concerns to the State Survey Agency. The DON acknowledged speaking with the CNA, who reported hearing a “crack” while repositioning the resident, and acknowledged speaking with the representative, who questioned how the fractures could have occurred when repositioning had been done many times previously without incident. The DON and Administrator stated they did not initiate an abuse investigation or report the incident to the State Survey Agency because, based on the resident’s history of fractures and comorbidities, they did not consider the event or the representative’s concerns to be an allegation of abuse or neglect, and as of survey exit the facility could not provide additional information explaining why the potential mistreatment was not reported.
Failure to Investigate Alleged Abuse After Resident Sustained Rib Fractures During Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of possible abuse or mistreatment/neglect after a resident sustained new rib fractures associated with staff-assisted repositioning. The facility’s Abuse Prevention Program policy requires that all incidents be documented and that, for injuries not initially involving an allegation of abuse or neglect, an appointed investigator gather facts to determine whether the injury should be classified as an injury of unknown source. The policy further requires that the investigator, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident if interviewable, and other residents and employees who regularly interacted with the accused staff member, as well as review written statements and pertinent medical records. The resident at issue had multiple significant comorbidities, including a left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, sacral pressure ulcer, GERD, and a history of repeated falls. The resident’s care plan and physician orders specified that she required assistance of one staff member for ADLs, toileting, and bed mobility, with Q2–3 hour repositioning using a wedge from right side to back, and that she was fragile with multiple prior fractures. On the evening in question, while being repositioned in bed by a CNA, the resident complained of severe sharp, stabbing pain in the left ribs upon palpation. The CNA reported hearing a “crack” during repositioning and notified the nurse, who assessed the resident, administered PRN Tramadol, and subsequently sent the resident to the ER when pain remained uncontrolled. Hospital imaging identified suspected new fractures of the left 7th and 8th anterior ribs, along with old bilateral rib fractures and thoracic compression fractures. Following this event, the resident’s representative reported concerns to facility leadership that a CNA had entered the resident’s room agitated and aggressive about the use of the call light, and allegedly grabbed the resident around the torso and yanked her backward in bed, which the representative believed caused the rib fractures. The representative also reported to the State Survey agency that they were not aware of any action taken after the first incident and that the resident was transported to the hospital the next day for the second incident. Despite these concerns, the DON stated that she concluded no investigation was needed, relying on the physician’s opinion that the injury was of known source due to the resident’s comorbidities and fragility. The DON acknowledged speaking only with the CNA involved and not interviewing other staff on duty, other residents, or others who might have knowledge of the CNA’s demeanor or any issues between the CNA and the resident. The DON also stated she did not consider the representative’s questions and concerns as an allegation of abuse or neglect. As of survey exit, the facility was unable to provide additional information explaining why a thorough investigation into potential mistreatment during the repositioning was not conducted, contrary to the facility’s own abuse investigation procedures.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for all residents on the 3rd floor, as evidenced by multiple observations of unsanitary conditions. Surveyors noted dirty, stained carpeting throughout the resident hallway, a persistent urine odor in the hallway, and debris including dead insects in most of the ceiling light fixtures. Additionally, two fans in the resident dining area were observed to be covered in dirt, dust, and debris, and the floor transition area of the back elevator was found to be littered with food particles and debris, which interfered with the elevator's operation until the surveyor manually cleared some of the obstruction. Further observations on subsequent days confirmed that these conditions persisted, with the same urine odor, dirty carpets, debris in light fixtures, and unclean fans remaining unaddressed. The hallway carpet was also found to have scraps from breakfast, paper lids, and condiment package pieces. The elevator continued to have food particles and a wrapper in the door slides, and the fans in the dining area remained caked with dust and debris, especially concerning given their proximity to resident food service areas. Interviews with the Environmental Services Director and Maintenance Supervisor revealed a lack of established cleaning schedules or documentation for the cleaning of carpets, light fixtures, and fans. Housekeeping staff were not responsible for full carpet cleaning, only spot cleaning, and there was no routine schedule for cleaning light fixtures or fans. The facility contracted out carpet cleaning services, but could not provide any invoices, contracts, or records to verify when cleaning had last occurred. Maintenance and environmental services staff indicated that cleaning was performed only when dirt was noticed or reported, rather than on a scheduled basis, and no documentation or logs were maintained to track these activities.
Inadequate Infection Control and Water Management in Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of a comprehensive water management plan and improper use of personal protective equipment (PPE) for a resident on droplet precautions. The facility did not have a current water management plan that included specific flow charts to identify areas of concern or interventions for closed units to prevent the spread of pathogens like Legionella. The Environmental Service Director admitted to not keeping up with documentation, and the water management binder lacked evidence of a risk assessment or plan for the closed 2nd floor unit. Observations revealed that the 2nd floor closed unit was in disarray, with dirty hallways and rooms containing garbage, debris, and equipment. Toilets in the unit were either dry or contained water with rust and debris, indicating a lack of regular flushing and maintenance. Despite claims from the Environmental Service Director that weekly flushing occurred, there was no documentation to support this, and the facility's water management plan did not address the specific risks associated with the closed unit. Additionally, the facility failed to ensure proper PPE usage for a resident on droplet precautions. A resident with multiple chronic conditions, including pneumonia, was placed on droplet precautions, but staff did not consistently wear the required PPE, such as masks and eye protection, when entering the resident's room. The Director of Nursing was unaware of the need for eye protection under droplet precautions, and the PPE carts lacked necessary items like face shields. This oversight in infection control practices had the potential to affect all residents in the facility.
Failure to Provide Written Transfer Notices to Residents
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to five residents (R8, R9, R19, R41, and R42) or their representatives, as required by state and federal regulations. Each of these residents was transferred to the hospital due to a change in condition, but there was no evidence that they or their representatives received the necessary written notice, which should include the reason for the transfer, the effective date, and the location to which the resident was transferred. The facility's policy mandates that such notifications be provided in writing and in a language and manner that the resident or their representative understands. For R8, the facility's records showed that the resident was agreeable to the transfer, but there was no written notification with a signature from the resident or their representative. The Nursing Home Administrator (NHA) admitted that sometimes due to the emergent nature of hospitalizations, the floor nurse might not obtain a signature, and in such cases, verbal communication is used, but this was not documented. Similarly, R9 was transferred without a written notice, and the NHA stated that while they try to send the Transfer Notice with residents, it is not part of the transfer paperwork to the hospital. R19, R41, and R42 also did not receive written notifications of their transfers. In R19's case, the NHA provided a notification signed by themselves, indicating a verbal discussion, but not by the resident or their representative. For R41 and R42, the facility was unable to provide any evidence that the residents or their representatives were notified in writing about the transfer and discharge. The surveyor noted these deficiencies and requested additional information, but the facility did not provide further documentation.
Failure to Administer Timely Vaccinations
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal and influenza immunizations as required by state and federal regulations. Two residents, identified as R10 and R20, did not receive the pneumococcal vaccine as requested. Additionally, R20 did not receive the influenza vaccine for the current season. The facility's policy mandates that residents be offered these immunizations unless medically contraindicated or already administered, but this was not adhered to in these cases. R10's medical record indicated a pending pneumococcal immunization consent confirmed by the Director of Nursing (DON) on 10/25/23, yet the vaccine had not been administered by the time of the survey. The DON mentioned that the pharmacy coordinates vaccine clinics and waits until 15 residents need the vaccine before scheduling, which led to delays. Similarly, R20's record showed a pending pneumococcal immunization consent confirmed on 12/6/24, and the influenza vaccine administered in March 2024 was for the previous season, not the current one. The DON acknowledged these oversights during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident. Specifically, the resident did not receive the prescribed strength of folic acid, as the facility administered a stock medication at a different dose. Additionally, the facility did not have the resident's Disulfram medication available for administration. The facility's medication policy requires that medications be administered as prescribed, following the Five Rights of medication administration. The resident was admitted with diagnoses including dementia and was prescribed folic acid and Disulfram for alcohol abuse disorder. During a medication administration observation, a Med Tech administered a 400 mcg dose of folic acid instead of the prescribed 1 mg. The Disulfram was not administered as it was not available in the facility. The MAR indicated discrepancies in the recorded administration of these medications, and interviews with facility staff confirmed the unavailability of the medications and the error in dosing.
Failure to Prevent Accident Hazards and Implement Fall Interventions
Penalty
Summary
The facility failed to eliminate accident hazards and provide adequate supervision to prevent accidents, affecting all 22 residents on a specific unit. Among these residents, several had cognitive impairments, including moderate and severe cases. A significant issue was identified with the storage and supervision of insulin and blood glucose medications. On multiple occasions, a treatment cart containing these medications was left unattended and accessible, contrary to the facility's policy that requires medications to be locked when not in use. This lapse in protocol was confirmed through observations and interviews with staff, including LPNs and the Director of Nursing. Additionally, the facility did not implement fall interventions for a resident with a high risk of falls, identified as R3. R3's care plan included specific interventions such as using a body pillow, maintaining the bed at the lowest position, and providing a soft touch call light. However, these interventions were not consistently in place. Observations revealed that R3's bed was often not at the lowest position, the body pillow was missing, and the call light was not the soft touch type as required. These deficiencies were noted over several days, indicating a failure to adhere to the care plan designed to prevent falls. R3, who has Alzheimer's Disease, dementia, and other health conditions, was assessed as having severe cognitive impairment and required substantial assistance for daily activities. Despite these needs, the facility did not ensure that the necessary safety measures were consistently applied. Interviews with staff confirmed that the care plan and Kardex were not followed, leading to potential safety risks for R3. The lack of adherence to established protocols and care plans highlights significant deficiencies in the facility's supervision and accident prevention measures.
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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 West Allis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunrise Health Services | 1.7 mi | ★★★★★ | 1 | 0 |
| Mercy Health Services | 1.7 mi | ★★★★★ | 3 | 0 |
| St Ann Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 11 | 0 |
| Maplewood Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Wheaton Franciscan Hc - Terrace At St Francis | 2.3 mi | ★★★★★ | 38 | 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.