Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Aria at Mitchell Manor
WEST ALLIS, WI · 50 certified beds · Last Life Safety survey January 29, 2025
CMS Certification Number 525600 · first certified July 1996
Ownership
Independently operated (no chain recorded by CMS) · For profit - Individual
- Ownership changed December 17, 2020 (change of ownership)from SNH WIS TENANT LLC
Position within WI
15 citations — more than 38% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to May 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 21, 2022 | 5 |
| October 16, 2023 | 4 |
| January 29, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-01-29 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-01-29 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2025-01-29 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2025-01-29 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2023-10-16 |
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | 1 | 2023-10-16 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2023-10-16 |
| K-0221 | Provide rooms that can be unlocked from inside without a key. | 1 | 2022-07-21 |
What the citations cover
- Smoke Deficiencies 7
- Emergency Preparedness Deficiencies 3
- Egress Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 29, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (February 20, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (February 20, 2025) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (February 20, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 20, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 20, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 20, 2025) |
October 16, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 6, 2023) |
July 21, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0221 | Provide rooms that can be unlocked from inside without a key. | Deficient, Provider has date of correction (August 12, 2022) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (August 12, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 12, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 12, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 12, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.