Mitchell Care Center
1723 23rd Street, Mitchell, NE 69357
Mitchell Care Center is a nursing home in Mitchell, Nebraska. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (308) 623-1212
- Last standard health inspection
- September 10, 2025 (1 year ago)
- Certified beds
- 50
- Residents per day, on average
- 47.1
- Ownership type
- Government - City/county
- Legal business name
- City of Mitchell
- Chain
- Rural Health Development
- Takes part in
- Medicare and Medicaid
More health citations than the Nebraska average (20 vs 19).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
1 citation
Health inspection on July 15, 2026
CMS lists this as a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on August 28, 2026.
CMS has cited this home for F0812 3 times since 2023.
CMS update of May 27, 2026
Ownership
CMS lists this home under a new chain.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of January 14, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 3 of 5.
CMS update of December 15, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
3 citations
Health inspection on September 10, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on October 25, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 25, 2025.
CMS has cited this home for F0684 2 times since 2024.
Citation F0607. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on October 25, 2025.
CMS has cited this home for F0607 2 times since 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
3 citations
Health inspection on June 17, 2025
CMS lists this as a complaint inspection.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on July 17, 2025.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on July 17, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 17, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.9 to 3.4 hours per resident per day.
CMS update of August 29, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
6 citations
Health inspection on August 13, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 12, 2024.
Citation F0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have enough outside ventilation via a window or mechanical ventilation, or both.
CMS lists it as corrected on September 12, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 12, 2024.
CMS has cited this home for F0880 2 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 12, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on September 12, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on September 12, 2024.
5 citations
Fire safety inspection on August 13, 2024
CMS lists this as a standard inspection.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on August 22, 2024.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on September 13, 2024.
CMS has cited this home for K0222 2 times since 2022.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on September 12, 2024.
CMS has cited this home for K0761 3 times since 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 22, 2024.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on September 20, 2024.
CMS has cited this home for K0921 2 times since 2023.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of May 29, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
7 citations
Health inspection on September 26, 2023
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 10, 2023.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS lists it as corrected on November 10, 2023.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS lists it as corrected on November 10, 2023.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on November 10, 2023.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on November 10, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 10, 2023.
Citation F0657. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 10, 2023.
3 citations
Fire safety inspection on September 26, 2023
CMS lists this as a standard inspection.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on October 26, 2023.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on October 26, 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on October 26, 2023.
6 citations
Fire safety inspection on July 26, 2022
CMS lists this as a standard inspection.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on August 26, 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 18, 2022.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 26, 2022.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on August 25, 2022.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 19, 2022.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on August 18, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CITY OF MITCHELL5% or greater direct ownership interest · 100% · since 02/04/1992
- RURAL HEALTH DEVELOPMENT INC.Operational/managerial control · not applicable · since 02/01/2014
Questions
When was Mitchell Care Center last inspected?
CMS lists September 10, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Mitchell Care Center have?
CMS lists 20 health citations since September 26, 2023. CMS also calls these deficiencies.
Has Mitchell Care Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Mitchell Care Center?
Its CMS overall star rating is 3 of 5.
Is Mitchell Care Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.