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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.49
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
12,659
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.12% · Performance 21.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.54
Baseline 5.76% · Performance 7.37% · Measure score 1.54 · Achievement 1.54 · Improvement 0
Total nurse turnover
0.71
Baseline 39.47% · Performance 60.78% · Measure score 0.71 · Achievement 0.71 · Improvement 0
Adjusted total nurse staffing
2.23
Baseline 3.34 hours · Performance 3.71 hours · Measure score 2.23 · Achievement 2.23 · Improvement 1.03
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 8.57% · Lower 95% interval 6.68% |
| Discharge to community | 42.56% |
50.57%
8 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 31.58% · Lower 95% interval 29.29% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 52 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 51.28% |
53.69%
2.4 pts worse
|
Numerator 20 · Denominator 39 |
| Discharge mobility score | 58.97% |
50.94%
8 pts better
|
Numerator 23 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 13.46% |
2.29%
11.2 pts worse
|
Numerator 7 · Denominator 52 · Adjusted rate 11.99% |
| Healthcare-associated infections requiring hospitalization | 7.37% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 10% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 4.41% |
8.2%
3.8 pts worse
|
Numerator 3 · Denominator 68 |
| Staff flu vaccination coverage | 25.93% |
42%
16.1 pts worse
|
Numerator 21 · Denominator 81 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 21 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28% |
25.2%
2.8 pts better
|
Numerator 7 · Denominator 25 |
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 · Adjusted 1.6 · Observed 2.2 · Expected 2.6 · Used in QM five-star |
| 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 · Adjusted 1.8 · Observed 2.1 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 98.0% |
| 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 · Q1 2.4% · Q2 0.0% · Q3 2.2% · Q4 2.4% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 11.9% · Q2 21.6% · Q3 16.3% · Q4 16.7% · 4Q avg 16.5% |
| 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 · Q1 6.7% · Q2 18.9% · Q3 21.1% · Q4 5.3% · 4Q avg 13.3% |
| 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 · Q1 22.9% · Q2 17.1% · Q3 18.2% · Q4 12.8% · 4Q avg 17.6% |
| 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 · Q1 23.3% · Q2 19.4% · Q3 13.3% · Q4 18.2% · 4Q avg 18.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q3 9.0% · Q4 23.4% · 4Q avg 14.5% · Used in QM five-star |
| 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 · Q1 6.1% · Q2 15.4% · Q3 14.0% · Q4 44.7% · 4Q avg 20.3% · Used in QM five-star |
| 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 · Q1 2.7% · Q2 2.8% · Q3 2.6% · Q4 7.7% · 4Q avg 4.0% · Used in QM five-star |
| 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 · Q1 8.3% · Q2 10.0% · Q3 10.0% · Q4 4.9% · 4Q avg 8.3% · Used in QM five-star |
| 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 · Q1 11.3% · Q2 15.2% · Q3 21.1% · Q4 2.4% · 4Q avg 12.7% |
| 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 · Q1 2.2% · Q2 2.5% · Q3 2.4% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 95.2% · Q3 100.0% · Q4 92.6% · 4Q avg 96.7% |
| 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 · Adjusted 13.5% · Observed 15.0% · Expected 12.4% · Used in QM five-star |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 90.5% |
| 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 · Adjusted 23.4% · Observed 22.5% · Expected 22.9% · Used in QM five-star |
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
Scottsbluff, NE
1-star overall rating with 1-star inspections with Special Focus status with $59,382 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Scottsbluff, NE
1-star overall rating with 1-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Gering, NE
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out