MITCHELL MANOR

The information listed below provides an in-depth look into the type and quality of care offered at Mitchell Manor. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

MITCHELL MANOR
5301 W LINCOLN AVE
WEST ALLIS, WI 53219
(414) 615-7200

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

95%

Number of Residents and Certified Beds

  • Residents: 70
  • Certified Beds: 74

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By For Profit - Corporation
  • Offers Only Resident Counseling
  • Part of a Continuing Care Retirement Community (CCRC)
  • This Facility is Part of a Chain or Franchise

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Nearby Cities:

Milwaukee | Greenfield | Greendale

Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Mitchell Manor. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation Plus Extensive Services

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
  • Tracheostomy care
  • Ventilator or respirator
  • Isolation for active infectious disease while a resident
  • Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 11-163.4%
ADL Index Range: 2-1010.9%
Total Percent:14.3%
 

Very High Rehabilitation Plus Extensive Services

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • Tracheostomy care
  • Ventilator or respirator
  • Isolation for active infectious disease while a resident
  • Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 2-101.1%
Total Percent:1.1%
 

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 11-1617.8%
ADL Index Range: 6-1023.2%
ADL Index Range: 0-516.7%
Total Percent:57.7%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-166.1%
ADL Index Range: 6-105.5%
ADL Index Range: 0-52.3%
Total Percent:13.9%
 

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum
  • Five days any combination of three rehabilitation disciplines
ADL Index Range: 11-163.6%
ADL Index Range: 0-50.2%
Total Percent:3.9%
 

Clinically Complex

  • Pneumonia, hemiplegia with ADL score >=5
  • Surgical wounds or open lesions with treatment
  • Burns
  • Chemotherapy while a resident
  • Oxygen therapy while a resident
  • IV medications or transfusions while a resident
  • Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
ADL Index Range: 0-1
- No Signs of depression
6.1%
Total Percent:6.1%
 

Reduced Physical Function

  • Urinary and/or bowel training program
  • Passive and/or active range of motion (ROM)
  • Amputation/prosthesis training
  • Dressing or grooming training
  • Eating or swallowing training
  • Transfer training
  • Splint or brace assistance
  • Bed mobility and/or walking training
  • Communication training
ADL Index Range: 15-16
- Less restorative nursing
1.2%
ADL Index Range: 6-10
- Less restorative nursing
2.0%
Total Percent:3.2%
 

Rating Details For Mitchell Manor

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours22 Minutes1 Hour and 4 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours1 Hour38 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 23 Minutes2 Hours and 32 Minutes
Total Licensed Nurse Hours1 Hour and 22 Minutes1 Hour and 43 Minutes
Total Nurse Hours3 Hours and 45 Minutes4 Hours and 15 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Wisconsin are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityWisconsin Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%94%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%95%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Had a Urinary Tract Infection6%8%
Percent of Long-Stay Residents Who Are More Depressed or Anxious16%18%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain2%4%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair1%3%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse6%11%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder81%49%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores5%8%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder4%7%
Percent of Long-Stay Residents Who Were Physically Restrained2%3%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased5%14%
Percent of Long-Stay Residents Who Lose Too Much Weight11%8%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination83%92%
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season88%90%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Have Pressure Sores4%10%
Percent of Short-Stay Residents Who Have Delirium3%3%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain16%26%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 06/30/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Environmental

Provide Rooms That Are Big Enough for Each Resident.
  • Inspection Date: 06/30/2009
  • Correction Date: 07/22/2009
Get Rid of Garbage Properly.
  • Inspection Date: 08/16/2010
  • Correction Date: 08/16/2010
Provide Rooms That Are Big Enough for Each Resident.
  • Inspection Date: 08/16/2010
  • Correction Date: 09/16/2010
Provide Needed Housekeeping and Maintenance.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900
Provide Rooms That Are Big Enough for Each Resident.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900

Quality Care

Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 06/30/2009
  • Correction Date: 07/22/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900

Resident Rights

Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged.
  • Inspection Date: 06/30/2009
  • Correction Date: 07/22/2009
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
  • Inspection Date: 06/30/2009
  • Correction Date: 07/22/2009
Provide Services to Meet the Needs and Preferences of Each Resident.
  • Inspection Date: 06/30/2009
  • Correction Date: 07/22/2009
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
  • Inspection Date: 06/30/2011
  • Correction Date: 01/01/1900

Enforcement

Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.

Action TakenDateAmount
Civil Money Penalty (CMP)06/30/2009$5,720

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for Mitchell Manor, as well as complaints by residents or their family in the previous three years.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Formal ComplaintsDegree of HarmResidents Affected

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Complaint Filed: 06/30/2009
  • Correction Date: 07/22/2009

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
  • Complaint Filed: 08/16/2010
  • Correction Date: 09/16/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
  • Complaint Filed: 08/16/2010
  • Correction Date: 09/16/2010

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Mitchell Manor had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 06/29/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010
An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 06/29/2011
  • Correction Date: 01/01/1900

Building Construction

A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009
Fire-Resistant Interior Walls.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009
A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010

Electrical

Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009
Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010
A Separate and Independent Backup Electrical Power Source.
  • Inspection Date: 06/29/2011
  • Correction Date: 01/01/1900

Emergency Plans and Fire Drills

Did Not Have a Written Emergency Evacuation Plan.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010

Fire Alarm Systems

An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 06/29/2011
  • Correction Date: 01/01/1900
Restrictions on the Use of Flammable Curtains.
  • Inspection Date: 06/29/2011
  • Correction Date: 01/01/1900

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 06/29/2011
  • Correction Date: 01/01/1900

Illumination and Emergency Power

Emergency Lighting That Can Last at Least 1 1/2 Hours.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009

Miscellaneous

Fire Safety Features Required by Current Fire Safety Codes.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009

Vertical Openings

Protected Exits That Allow the Resident to Escape the Building.
  • Inspection Date: 08/13/2009
  • Correction Date: 09/13/2009
Protected Exits That Allow the Resident to Escape the Building.
  • Inspection Date: 09/17/2010
  • Correction Date: 09/26/2010
Source: Medicare Nursing Home Compare; Dept of Health and Family Services of WI-Division of Supportive Living-Bureau of Quality Assurance - Retrieved 2011