Mitchell, NE
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1723 23rd Street, Mitchell, NE
(308) 623-1212
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
50
Certified beds
Average residents
46
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.49
Registered nurse staffing
LPN hours / resident day
0.79
Licensed practical nurse staffing
Aide hours / resident day
2.45
Nurse aide staffing
Weekend hours
3.01
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
33%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.8%
7.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
96.1%
1.9 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
4.5%
2.8 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 16.5% |
4.4%
12.1 pts worse
|
11.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 13.3% |
5.3%
8 pts worse
|
5.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
19.5%
1.9 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.5% |
21.6%
3.1 pts better
|
16.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.5% |
20.4%
5.9 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
19.9%
0.4 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
1.6%
2.4 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 8.3% |
2.9%
5.4 pts worse
|
1.7%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.7% |
26.6%
13.9 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.3%
2 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
80.5%
16.2 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
11.6%
1.9 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
75.9%
14.6 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
20.9%
2.5 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-22
Fire Safety
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.
Corrected 2024-09-13
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-22
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-26
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-10-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-26
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-26
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-26
Fire Safety
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.
Corrected 2022-08-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-19
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-18
Inspection history
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-10-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-25
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-25
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-17
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-12
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2024-09-12
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-12
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-12
Health
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.
Corrected 2024-09-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-10
Health
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.
Corrected 2023-11-10
Health
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.
Corrected 2023-11-10
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-10
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-10
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-10
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-10
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
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