Mitchell Manor: Resident Left Alone in Van - IN
The incident, which came to light through a federal complaint inspection completed August 18, unfolded on or around July 24, 2025, when the driver took the resident, identified in inspection records only as Resident B, to a doctor's appointment. Resident B has chronic obstructive pulmonary disease and depression.
On the way back, the driver stopped at a restaurant drive-through and bought lunch for himself, his wife, and the resident. He then drove to a nearby hospital and got out of the vehicle to bring his wife her meal inside the building. He left Resident B alone in the van.
The driver had left the air conditioning running when he got out. Resident B, left alone in the vehicle, rolled down the window and turned the van off.
After approximately 15 minutes, Resident B climbed out of the van and walked into the hospital to find the driver. A hospital security guard met her, got her a wheelchair, and stayed with her until the driver came back out.
When the driver returned, he asked Resident B not to say anything about what had happened. He had bought her lunch, he told her.
Resident B didn't report the incident for more than a week.
Inspectors checked weather records for the week of July 24 through July 28 using the Weather Underground website. The average high temperature that week in the area was 90 degrees.
The facility's own accident documentation tells the story incompletely. A nursing progress note dated July 28 at 8:32 p.m. said the resident's family and physician had been notified of an alleged incident and that no signs of acute distress were noted. It said nothing about what the incident actually was. The clinical record, inspectors found, lacked any documentation of what had occurred.
The formal accident report, dated July 29, was where the driver's account appeared. He acknowledged he had stopped to bring his wife lunch at the hospital. He acknowledged he had left Resident B unattended in the vehicle. He said he knew he should not have done it.
The facility's administrator told inspectors the driver had stopped at a drive-through and then at the hospital before the resident was left alone. She confirmed the driver asked Resident B to stay quiet.
The director of nursing told inspectors she wasn't certain of the exact date because the resident had waited so long to come forward. She believed it happened on July 24, during the lunch hour.
Mitchell Manor's transportation policy, last revised May 15, 2025, three months before the inspection, states that the facility will ensure safety procedures are followed in accordance with state and federal guidance. Inspectors cited the facility for failing to ensure Resident B was supervised while riding in the facility van.
The violation was classified as causing minimal harm or potential for actual harm. Inspectors reviewed three residents for accident-related concerns and identified the problem in one case.
Resident B was out of the facility and unavailable for interview on the day inspectors arrived.
What the record does not show is what those 15 minutes felt like for a woman with a lung disease, sitting alone in a parked vehicle with the engine off and the window cracked, in 90-degree July heat, waiting for a driver who had asked her, before he walked away, to keep what was about to happen between the two of them.
She got out. She found her own way inside. A stranger with a wheelchair sat with her until the driver came back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mitchell Manor from 2025-08-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
MITCHELL MANOR in MITCHELL, IN was cited for violations during a health inspection on August 18, 2025.
Resident B has chronic obstructive pulmonary disease and depression.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.