Skip to main content
Complaint Investigation

Mitchell Care Center

September 10, 2025 · Mitchell, NE · 1723 23rd Street
Citations 3
CMS Rating 3/5
Beds 50
Provider ID 285287
Healthcare Facility
Mitchell Care Center
Mitchell, NE  ·  View full profile →
Inspection Summary

Mitchell Care Center in Mitchell, NE — inspection on September 10, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF0607
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for Minimal Harm

Federal health inspectors cited Mitchell Care Center in Mitchell, NE for a deficiency under regulatory tag F-F0607 during a standard health inspection conducted on 2025-09-10.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of Mitchell Care Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-25.

Federal health inspectors cited Mitchell Care Center in Mitchell, NE for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-09-10.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of Mitchell Care Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-25.

Based on record review and interview, the facility failed to ensure 2 of 5 sampled nurse aides (NA) completed the required 12 hours of ongoing training annually and failed to ensure 5 of 5 sampled NAs had completed 4 hours of Alzheimer's care and dementia care training annually.

This had the potential to affect all residents who reside within the facility.

The facility census was 42.

Findings Are: A record review of a facility document [NAME] Care Center Employee Hire and Release Dates dated 9/7/2025 revealed the following:-NA-C was hired on 6/25/2024,-NA-D was hired on 5/9/2024,-NA-E was hired on 8/10/2023,-NA-F was hired on 7/17/2023, and -NA-G was hired on 7/10/2019. A.A record review of a facility provided document Employee Training Tracker for NA-F for the timeframe of 7/10/2024-7/10/2025 revealed NA-F had completed 8 hours of ongoing training. A record review of a facility provided document Employee Training Tracker for NA-G for the timeframe of 7/17/2024-7/17/2025 revealed NA-G had completed 1 hour of ongoing training. An interview on 9/9/2025 at 9:55 AM with the Director of Nursing (DON) confirmed NA-F and NA-G had not completed the required 12 hours of ongoing training annually. B.A record review of a facility provided document Employee Training Tracker for NA-C for the timeframe of 6/25/2024 through 6/25/2025 revealed NA-C had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-D for the timeframe of 5/9/2024 through 5/9/2025 revealed NA-D had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-E for the timeframe of 8/10/2024 through 8/10/2025 revealed NA-E had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-F for the timeframe of 7/17/2024 through 7/17/2025 revealed NA-F had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-G for the timeframe of 7/10/2024 through 7/10/2025 revealed NA-G had not completed any Alzheimer's care or dementia care training. An interview on 9/9/2025 at 9:55 AM with the Director of Nursing (DON) confirmed NA-C, NA-D, NA-E, NA-F, and NA-G had not completed the required 4 hours of Alzheimer's care and dementia care training annually.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Mitchell, NE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Mitchell Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement