Aria at Mitchell Manor

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 45 residents residing in the facility. Staffing information for Quarter 2 (January 1 - March 31, 2026) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.

Inspectors wroteBased on interview and record review, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property affecting residents residing on the third floor. The facility did not ensure their abuse policy was implemented when Registered Nurse (RN)-M and Housekeeper-N did not have Background Information Disclosure (BID), Department of Justice (DOJ), and Integrated Background Information System (IBIS) background checks updated within four years of working at the facility. Certified Nursing Assistant (CNA)-I did not have Department of Justice (DOJ), and Integrated Background Information System (IBIS) background checks updated within four years of working at the facility. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure acceptable parameters of nutritional status were maintained or fluid intake was monitored for 4 (R7, R40, and R5) of 5 sampled residents reviewed for nutrition and hydration. *R7 had significant weight loss three times in 6 months that were not identified or acted on. R7 had a weight loss of 14 percent in 6 months and 9 percent in one month. *R40 had a significant weight loss of 7.9 percent in one month that was not identified or acted on. *R5 was on a daily fluid restriction. The facility did not monitor R5's daily fluid intake.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that drugs and biologicals used in the facility were labeled and include the expiration date, when applicable, for 5 (R34, R2, R36, R44, & R5) of 9's resident's insulin.*R34 & R2 insulin pens were together in the bottom of the medication cart and not in bags.*R36 & R44's insulin bottles were together in the bottom of the medication cart and not in a medication container. R5's lispro insulin was not dated when open & used.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure each resident is treated with dignity and respect that promotes maintenance or enhancement of quality of life for 1 (R39) of 13 residents.*On 6/28/26 Certified Nursing Assistant (CNA)-S stood while feeding R39.

Inspectors wroteBased on observation and interview the Facility did not ensure 1 (R45) of 12 residents were provided privacy during personal cares.*R45 was not ensured privacy during wound care when R45's door was left open during the care.

Inspectors wroteBased on interview and record review the facility did not ensure a resident who uses an as needed (PRN) psychotropic has an order limited for 14 days for 1 (R5) of 5 residents reviewed for unnecessary medication. R5 has an order for PRN lorazepam (Ativan) with an order date of 5/14/26. There is no end date for R5's PRN lorazepam and no documented rationale for continued use.

Inspectors wroteBased on interview and record review, the facility did not initiate or complete a comprehensive Significant Change Minimum Data Set (MDS) assessment within 14 days after a significant change was identified for 1 (R40) of 12 sampled residents reviewed. R40 started hospice services on 6/12/2026. On 6/30/2026, 18 days after the election of hospice, a Significant Change MDS assessment had not been scheduled or completed.

Inspectors wroteBased on 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 (R54) of 5 Residents reviewed for pressure injuries. On 4/1/26 Wound Nurse Practitioner (NP)-Z changed treatment orders for R54's left hip pressure injury. The facility did not implement this order.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R2) of 1 residents reviewed for Post-traumatic stress disorder (PTSD) receive culturally competent, trauma informed care in accordance with professional stands of practice and accounting or resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R2. R2 has a diagnosis of PTSD. There is not a PTSD assessment to identify R2's past history of trauma nor is there a person-centered PTSD care plan which includes what triggers R2's PTSD and interventions.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 4 medication errors in 30 opportunities which resulted in a medication error rate of 13.33%. Medication errors were identified for 1 (R44) of 2 residents observed. R44 did not receive the correct dose of Amantadine HCI & Valproic Acid, did not receive Multivitamins Plus Iron child oral tablet chewable 18 mg (milligrams) and Clear lax was not initially administered enterally according to physician orders.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R44) of 2 Residents during medication administration.* Appropriate hand hygiene was not observed during R44's medication administration.

Inspectors wroteBased on interview and record review, the facility did not ensure the pneumococcal immunization education was provided and the refusal was documented for 1 (R40) of 5 sampled residents reviewed for immunizations.*R40 did not have documentation of education with the benefits of the pneumococcal vaccine and the refusal or acceptance of the vaccine in the medical record.

Inspectors wroteBased on interview and record review, the facility did not ensure the COVID-19 immunization education was provided and the refusal was documented for 1 (R40) of 5 sampled residents reviewed for immunizations.*R40 did not have documentation of education with the benefits of the COVID-19 vaccine and the refusal or acceptance of the vaccine in the medical record.

Inspectors wroteBased on interview and record review, the facility did not address grievances by ensuring documentation of the concern, conducting a thorough investigation of the issues identified or provide resolution of the concerns brought to the attention of facility staff, for 1 (R1) of 3 residents reviewed for grievances. On 11/14/25 and 12/23/25, a representative for R1 expressed concerns to facility staff regarding the care R1 was receiving. The facility did not investigate and ensure a follow-up to the concerns expressed or provide details of a resolution regarding the grievance.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that they reported allegations of possible abuse or mistreatment to the State Survey Agency for 1 (R1) of 3 sampled residents. On 12/22/25, R1 was repositioned in bed by a facility Certified Nursing Assistant (CNA-D) when R1 experienced severe pain in her left ribs. R1 was sent to the emergency room and diagnosed with a fracture to the 7th and 8th anterior left ribs. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure that they thoroughly investigated allegations of possible abuse or mistreatment/ neglect for 1 (R1) of 3 sampled residents. R1 was repositioned in bed by CNA (Certified Nursing Assistant)-D on 12/22/25. While R1 was being repositioned with the assistance from CNA-D, R1 complained of severe pain to her ribs. R1 was sent to the emergency room on [DATE] where R1 was diagnosed with a fracture to the 7th and 8th anterior ribs. On 12/23/25 a representative for R1 raised concerns regarding possible mistreatment to R1 leading to t he sustained rib fractures. The facility did not thoroughly investigate the incident.

Inspectors wroteBased on observation and interview, the facility did not ensure the residents environment was clean, comfortable and homelike for 25 of 25 residents on the 3rd floor. During the Survey the 3rd floor was noted to have dirty stained carpeting in the resident hallway. Urine smell in 3rd floor resident hallway. Debris and dead insects in the light covers on the 3rd floor resident hallway. 2 fans used on the 3rd floor resident dining area were dirty and unclean. The floor transition on the back elevator was covered in food particles and debris. * The 3rd floor community hallway carpeting, light fixtures, back elevator and dining room fans were not maintained in a clean and sanitary manner.

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. * The facility does not have a current comprehensive water management plan that includes flow charts specific to the facility to determine areas of concern or interventions implemented on closed units to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems, and the water management plan was not included in the facility assessment. * R27 was on droplet precautions. Staff did not utilize proper PPE (Personal Protective Equipment) when entering his room. This deficient practice has the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 5 (R8, R9, R19, R41, and R42) of 5 residents reviewed for hospitalizations received a written notice of transfer/discharge to include resident or responsible party signature. * R8 was transferred to the hospital on [DATE] for a change in condition. R8 or their representative did not receive written notification of transfer to the hospital. * R9 was transferred to the hospital on 1/8/25 for a change in condition. R9 or their representative did not receive written notification of transfer to the hospital. * R19 was transferred to the hospital on [DATE] for a change in condition. R19 or their representative did not receive written notification of transfer to the hospital. * R41 was transferred to the hospital on [DATE] for a change in condition. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; and each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period, for 2 of 5 (R10 and R20) residents reviewed for immunizations. * R10 did not receive the Pneumococcal 20 vaccine as requested. * R20 did not receive the Pneumococcal 20 vaccine as requested and did not receive the Influenza vaccine for this years influenza season.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medications were available in the facility to administer as ordered for 1 (Resident (R) 2 out of a total sample of 10 residents reviewed. R2 did not receive Folic acid at the prescribed strength as the facility did not have R2's prescription in the facility and administered stock medication which was at a different dose than ordered. Additionally, the facility did not ensure R2's Disulfram was available to administer as ordered.

Inspectors wroteBased on observation, interview, and record review, the Facility did not eliminate accident hazards in the resident environment affecting 22 of 22 residents, of which, according to the Brief Interview for Mental Status scores of residents on this first floor unit, four have moderately impaired cognition and two have severe cognitive impairment. One (R3) of 3 residents reviewed for falls did not have their fall interventions in place. The Facility did not ensure insulin/blood glucose medications were kept in a secure location when not in use. R3's fall interventions were not in place on 8/22/2024 and 8/26/2024.

Inspectors wroteBased 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. * R39 was admitted to the facility on [DATE] with no skin impairment. R39 was assessed to be at risk for the development of pressure injuries. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure food was stored, prepared, or served in accordance with professional standards for food service safety potentially affecting all 48 residents in the facility. Food stored in the refrigerator and freezer were not labeled or dated, moldy vegetables were in the refrigerator, expired milk was used in cooking and was served to residents, and food temperatures were not documented on the temperature log for multiple meals during a week.

Inspectors wroteBased on observation, record review, staff and resident interviews, the facility did not ensure a pest control program effectively addressed rodents in the facility. This has the potential to affect all 48 residents that reside in the facility. Surveyors became aware of concerns with rodents, cockroaches and bed bugs within the facility. 3 of 4 residents (R10, R14, R30) who attended the Surveyor's resident council group meeting held on 10/4/23 expressed concerns regarding rodents in the facility.

Inspectors wroteBased on observation, interview and record review the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. On 10/03/23 Surveyor observed Licensed Practical Nurse (LPN)-R utilize a glucometer to conduct point of care testing for R23. LPN-R did not clean and disinfect the facility's shared glucometer according to the manufacturer instructions. This deficient practice had the potential to affect 9 residents residing on the third floor.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents with non-pressure injuries received treatment in accordance with professional standards of practice for 2 (R41 and R396) of 3 residents reviewed for non-pressure injuries. * R41's rectovaginal wound had a treatment order for calcium alginate to the wound base. Licensed Practical Nurse (LPN)-J did not apply the treatment as ordered by the physician until Surveyor intervened. * R396's right hip incisional wound treatment was to apply gentamycin followed by calcium alginate and cover with a border dressing. Surveyor observed Licensed Practical Nurse (LPN)-J apply gentamycin to the area surrounding wound, not directly to the wound base, and use calcium alginate from an opened package that was in R396's room.