Mitchell Care Center

In the surveyor’s words

From the most serious findings on record at Mitchell Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 15, 2026

  Licensure reference number 175 NAC 12-006.11(E) Based on observation, record review, and interviews, the facility failed to ensure cold foods were maintained at a temperature below 41 degrees Fahrenheit, and hot foods were maintained at a temperature above 135 degrees Fahrenheit to prevent the potential for foodborne illness. This had the potential to affect all residents. The facility showed a census of 46.Findings are:During an interview at 11:01 AM on 7/15/26 Dietary [NAME] (DC)-B confirmed that all lunch foods had already been prepared and were in the steam table, and they would begin serving foods at 11:45 AM.An observation made at 11:01 AM on 7/15/26 revealed a large silver bowl filled with salad sitting on a cart next to the steam table.Continuous observations made between 11:35 AM… […]

• No harm, potential for more than minimal, widespreadF947Sep 10, 2025

  Licensure Reference Number 175 NAC 12-006.04(B)(ii)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) 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. […]

• No harm, potential for more than minimal, widespreadF812Aug 13, 2024

  LICENSURE REFERENCE NUMBER NAC 175 12-006.11(E) Based on observations, interviews, and record review; the facility failed to ensure foods were date-marked or labeled with their common names and failed to dispose of or consume foods within seven days as required to prevent the potential for food-borne illness. This had the potential to affect all 43 residents who resided within the facility and were served out of the kitchen. Findings are: A. A record review of the 2017 Nebraska Food Code revealed in section 3-602.11(C)(1) and (2) that bulk foods which are available for consumer self-dispensing shall be prominently labeled with the manufacturer's or processor's label that was provided with the food or a card, sign, or other method of notification that includes the required information. […]

• No harm, potential for more than minimal, widespreadF923Aug 13, 2024

  Licensure Reference Number 175 NAC 12-007.04D Based on record review, observation, and interview; the facility failed to ensure that the ventilation system was operational in resident's bathrooms on 100, 200, and 300 wings. This had the potential to affect all 43 residents who resided within the facility. Findings are: A record review of a policy Maintenance Service with a last revised date of December 2009 revealed function of maintenance personnel include maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. An observation on 8/8/2024 at 9:29 AM revealed a strong odor of bowel movement in the 100 wing. […]

• No harm, potential for more than minimal, widespreadF812Sep 26, 2023

  Licensure Reference Number 175 NAC 12-006.11E Based on observations, interview and record reviews, the facility failed to utilize proper hand hygiene practices during the preparation and serving of food to prevent the potential for foodborne illness. This had the potential to affect 46 of 47 residents who ate from the kitchen. Findings are: A. An observation on 9/21/2023 at 7:30 AM at the start of the breakfast meal service revealed Dietary Aide (DA-G) performed no hand hygiene prior to meal service. DA-G was observed grabbing plates and bowls with bare hands, placing fingers inside of the bowls and on top of the plates, sitting them down to fill with food and sending them out to the residents. DA-G then grabbed the menus and repeated the same process throughout breakfast food service. […]