Inspection Reports for
Mitchells Nursing Home, Inc.
501 W 10th, Danville, AR, 72833
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the management of residents' trust fund accounts, notification of account balances affecting Medicaid eligibility, and accuracy of resident assessments related to oxygen use.
Complaint Details
The complaint investigation revealed issues with trust fund account management affecting 18 residents, including improper interest allocation, lack of proper accounting and reconciliation, failure to notify residents of Medicaid eligibility risks due to account balances, and inaccurate resident assessments related to oxygen use for two residents.
Findings
The facility failed to properly manage residents' trust fund accounts by not providing separate accounting of interest, failing to maintain accurate accounting systems, not notifying residents of account balances exceeding Medicaid limits, and not coding oxygen use accurately on resident assessments for two residents.
Deficiencies (4)
Failed to provide separate accounting of interest to ensure 18 residents with trust fund accounts received all interest earned.
Failed to establish and maintain a system based on generally accepted accounting principles to ensure full and complete accounting of each resident's personal funds and failed to provide quarterly written accounting to residents or their representatives.
Failed to notify residents who received Medicaid or SSI when their account balances reached the $2,000 resource limit that could cause loss of eligibility.
Failed to ensure oxygen use was coded on the Minimum Data Set (MDS) for two residents to ensure accurate care planning, quality of life, and reimbursement.
Report Facts
Residents affected: 18
Resident accounts with balances over $2,000: 14
Funds in pooled trust fund account: 18470.21
Interest deposits: 0.37
Interest deposits: 0.31
Interest deposits: 0.25
Interest deposits: 0.28
Residents reviewed for oxygen coding: 8
Residents with oxygen coding deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager/Assistant Administrator | Responsible for managing trust fund accounts, interest allocation, and notifications; named in findings related to trust fund mismanagement | |
| Administrator | Provided statements regarding trust fund management expectations and deficiencies | |
| MDS Nurse #1 | MDS Nurse | Admitted oxygen use was not coded on MDS for Resident #5 and provided documentation |
| MDS Nurse #2 | MDS Nurse | Confirmed use of RAI manual for MDS coding and responsibility for coding oxygen use |
| Director of Nursing | Director of Nursing | Stated expectation that oxygen use would be documented on MDS |
| Administrator | Administrator | Stated expectation for accurate MDS completion and identified responsible MDS nurses |
Inspection Report
Routine
Deficiencies: 1
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically focusing on hand hygiene practices among staff.
Findings
The facility failed to ensure staff consistently washed or sanitized their hands after resident care and between feeding residents, as observed with multiple staff members including Licensed Practical Nurse #12, Certified Nursing Assistants, and the CNA/Medication Assistant Certified #1. The Infection Preventionist confirmed staff training responsibilities and proper hand hygiene procedures.
Deficiencies (1)
Failure to ensure staff washed their hands after resident care and between feeding residents.
Report Facts
Date of observation: May 28, 2024
Date of survey completion: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Observed failing to wash hands after resident care |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed failing to sanitize hands between assisting residents during meal service |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed about hand hygiene practices during meal service |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed about hand hygiene practices during meal service |
| CNA/Medication Assistant Certified #1 | CNA/Medication Assistant Certified | Observed failing to sanitize hands when exiting resident room |
| Director of Nursing | Director of Nursing | Provided statement on hand hygiene expectations |
| Infection Preventionist | Infection Preventionist | Responsible for training staff on hand hygiene and confirmed proper procedures |
Inspection Report
Routine
Deficiencies: 2
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations and infection prevention and control practices at Mitchell's Nursing Home.
Findings
The facility failed to ensure that over-the-counter medications were not expired and lacked a medication storage policy. Additionally, staff failed to consistently perform hand hygiene after resident care and between feeding residents, increasing the risk of infection transmission.
Deficiencies (2)
Failure to ensure over-the-counter medications were not expired and lack of a medication storage policy.
Failure to ensure staff washed their hands after resident care and between feeding residents.
Report Facts
Expired medication bottles: 20
Observation times: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Removed expired medication bottles and informed Director of Nursing |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Observed not washing hands after resident care and admitted forgetting to sanitize |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed not sanitizing hands between assisting residents during meal service |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed about hand hygiene importance during meal tray passing |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed about hand hygiene importance during meal tray passing |
| Certified Nursing Assistant/Medication Assistant Certified #1 | CNA/MAC | Observed not sanitizing hands after resident care |
| Director of Nursing | Director of Nursing | Stated facility lacked medication storage policy and emphasized hand hygiene |
| Infection Preventionist | Infection Preventionist | Responsible for training staff on hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 20, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident fall incident during a bed bath at Mitchell's Nursing Home.
Complaint Details
The complaint investigation found that the Certified Nurse Assistant bathed Resident #1 alone, asked the resident to hold the siderail, which broke due to a bent bolt, causing the resident to fall and sustain a laceration. The incident was substantiated with witness statements and facility investigation.
Findings
The facility failed to follow the plan of care to prevent Resident #1 from falling out of bed during a bed bath, resulting in a laceration and transfer to the emergency room. The side rail broke due to a bent bolt, causing the resident to fall.
Deficiencies (1)
Failed to follow the plan of care to prevent a resident from falling out of bed during a bed bath.
Report Facts
Residents sampled for accidents: 3
Resident cognitive assessment score: 15
Date of nurse's note: Jun 30, 2023
Date of witness statements: Jun 30, 2023
Date of CNA interview: Jul 19, 2023
Bolt size: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in the finding related to the resident fall during bed bath. |
| RN #1 | Registered Nurse | Completed witness statement and responded to the fall incident. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 28, 2023
Visit Reason
The inspection was conducted to investigate complaints related to failure in timely notification of resident discharge, PASARR screening for mental disorders, respiratory care practices, medication error rates, and food safety and hygiene practices in the nursing home.
Complaint Details
The visit was complaint-related, investigating issues including failure to notify resident representatives of discharge, failure to conduct PASARR screenings, respiratory care deficiencies, medication errors, and food safety violations. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to provide timely discharge notification to resident representatives, failure to conduct required PASARR screenings, inadequate respiratory care practices such as improper oxygen tubing and CPAP mask handling, medication administration errors exceeding 5%, and unsafe food handling and hygiene practices that could lead to cross contamination.
Deficiencies (5)
Failure to provide timely notification to resident's representative and ombudsman before discharge.
Failure to refer resident with mental illness to state-designated authority for PASARR evaluation.
Failure to post oxygen signs, change oxygen tubing weekly, date humidifier bottles, and store CPAP equipment properly to prevent cross contamination.
Medication error rate exceeded 5% with errors in administration and holding of medications without proper notification.
Failure to ensure safe food handling practices including lack of hand sanitization between serving trays, improper disposal of biohazard bags, and improper storage of food items.
Report Facts
Residents affected: 1
Residents affected: 14
Residents affected: 6
Residents affected: 28
Residents affected: 78
Medication pass opportunities observed: 45
Medication errors observed: 4
Medication error rate: 8.89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Named in findings related to failure to notify family about discharge and medication administration expectations | |
| Administrator | Provided documentation and statements regarding discharge notification and facility policies | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding oxygen tubing, humidifier changes, and signage responsibilities | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding medication holding policy and medication administration | |
| Registered Nurse (RN) #1 | Interviewed regarding medication administration and facility policies | |
| Dietary Manager | Interviewed regarding food handling, tray passing, and kitchen hygiene practices | |
| Certified Nursing Assistant (CNA) #4, #5, #6, #7 | Observed and interviewed regarding food service and hygiene practices | |
| Social Director | Observed passing out lunch trays without sanitizing hands | |
| Medical Records Nurse | Responsible for PASARR referrals as stated in interview | |
| Assistant Administrator | Interviewed regarding PASARR referral responsibilities |
Viewing
Loading inspection reports...
