Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mitchell Care Center during CMS and state inspections, most recent first.
The facility did not ensure that two nurse aides completed the required 12 hours of annual training, and five nurse aides did not complete the mandated 4 hours of Alzheimer's and dementia care education. The DON confirmed these training deficiencies, which had the potential to affect all residents.
Two residents experienced multiple episodes of constipation without appropriate assessment or intervention, despite facility policy and physician orders requiring action. One resident, taking medications associated with constipation, went several days without a bowel movement and did not receive required GI assessments or bowel medications. Another resident had similar periods without a bowel movement, with no evidence of PRN medication administration or documented assessment, even though a bowel management protocol was in place.
Required Nurse Aide Registry checks were not completed for an LPN and a Maintenance Assistant, both of whom could have unsupervised access to residents. Facility policy required verification of board registrations and certifications, but this step was missed for these two employees, as confirmed by the Administrator.
The facility did not implement or document procedures to protect residents from further abuse during an investigation involving an LPN and two residents. The abuse policy lacked required procedures, and there was no evidence that the LPN was suspended or that protective measures were taken while the investigation was ongoing.
The facility did not suspend or restrict an LPN accused of abuse during an investigation, allowing the LPN continued access to residents. The DON, who is related to the LPN, handled the investigation without removing the LPN from duty, and initial documentation of the investigation was lacking. The LPN's absence from work following the incident was due to the original schedule, not as a protective measure.
The facility did not report an allegation of abuse involving an LPN and two residents to the State Agency as required by policy. The DON, who is related to the LPN, conducted an internal investigation but did not document or report the findings, believing no abuse had occurred. The NHA confirmed the lack of reporting and documentation, acknowledging the deficiency.
The facility failed to properly label and date-mark food items, risking potential food-borne illnesses. Observations revealed unlabeled bins and bags of food, and expired items used in meal preparation. Interviews confirmed these deficiencies, affecting all 43 residents served by the kitchen.
The facility failed to maintain operational ventilation systems in the bathrooms of the 100, 200, and 300 wings, affecting all 43 residents. A strong odor was detected, and inspections showed that the ventilation systems in several rooms were not functional. The Administrator and Maintenance Personnel confirmed the issue.
The facility failed to implement proper infection control measures, including the use of enhanced barrier precautions and hand hygiene. A resident with a stage 4 pressure ulcer did not receive care with the required PPE, and staff did not follow hand hygiene protocols during catheter care and medication administration, leading to contamination risks.
A resident on hypertension medication did not have their blood pressure monitored weekly as required by the facility's protocol. Despite being on Amlodipine Besylate and Lisinopril, there was no order for weekly monitoring, leading to significant gaps in blood pressure readings. The DON confirmed the oversight, which resulted in the resident experiencing critical blood pressure fluctuations, including a hospital admission.
A facility failed to ensure a pharmacist identified irregularities during monthly medication regimen reviews for a resident with severe cognitive impairment. The resident had an order for PRN Ativan without a stop date, which was not flagged as an irregularity from March to August. The pharmacist later confirmed this oversight.
A facility failed to ensure a PRN Ativan order for a resident with severe cognitive impairment had a stop date, as required by their policy. The policy states that PRN psychotropic medications should be used for a limited duration unless extended with documented rationale. This deficiency was confirmed by the DON during an interview.
Failure to Ensure Required Nurse Aide Training and Dementia Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required annual training hours and specific education in Alzheimer's and dementia care. Record reviews showed that two nurse aides did not complete the mandated 12 hours of ongoing training within the annual period, with one aide completing only 8 hours and another just 1 hour. The Director of Nursing confirmed these deficiencies during an interview. Additionally, five nurse aides did not complete the required 4 hours of annual training in Alzheimer's care and dementia care. Documentation for each of these aides indicated no evidence of such training during the specified timeframes. The Director of Nursing also confirmed that these nurse aides had not fulfilled the annual dementia care training requirement. These failures had the potential to affect all residents in the facility, which had a census of 42 at the time.
Failure to Implement Bowel Management Program for Two Residents
Penalty
Summary
The facility failed to implement its bowel management program as outlined in its policy and procedure, resulting in inadequate prevention and management of constipation for two residents. For one resident, who was always incontinent of bowels and taking medications known to cause constipation, there were multiple documented periods of three to five days without a bowel movement. During these periods, there was no evidence of gastrointestinal assessments, progress notes, or administration of bowel medications as required by the facility's protocol. The Medication Administration Record showed only a single administration of a bowel medication, with no further interventions or documentation of effectiveness, and the Director of Nursing confirmed that the protocol was not followed. For another resident, documentation showed several episodes of three to four days without a bowel movement. Although there was a physician's order for a PRN bowel medication, there was no evidence in the Medication Administration Record or progress notes that the medication was administered during these episodes. Additionally, there were no assessments or interventions documented in response to the lack of bowel movements, despite the resident being under a fluid restriction and having a care plan that addressed bowel continence. Interviews with nursing staff confirmed the lack of documentation and intervention according to the facility's bowel management protocol.
Failure to Complete Required Nurse Aide Registry Checks for Staff
Penalty
Summary
The facility failed to complete required Nurse Aide Registry checks for two of five sampled employees, specifically an LPN and a Maintenance Assistant, both of whom had the potential for unsupervised access to all residents. Record reviews showed that neither employee had documentation of a completed Nurse Aide Registry check in their personnel files. The facility's policy required verification of board registrations and certifications for prospective employees, but this process was not followed for these two staff members. The Administrator confirmed during an interview that the checks had not been completed for these employees.
Failure to Protect Residents During Abuse Investigation
Penalty
Summary
The facility failed to implement and document effective policies and procedures to prevent further abuse during the investigation of abuse allegations. A review of the facility's abuse policy revealed it did not include procedures for protecting residents while abuse allegations were being investigated, nor did it document how residents would be protected in reports to the State Agency. Additionally, an investigative summary regarding an incident involving an LPN and two residents did not contain evidence of measures taken to protect residents during the investigation. The summary only described interviews conducted by the DON and education provided to the LPN, without specifying any protective actions. Interviews with staff and administration confirmed that the alleged employee was not suspended or formally removed from duty during the investigation. The DON stated that the LPN was not suspended because they believed nothing had happened, and the NHA confirmed there was no documentation of suspension or protective measures. Staff statements and investigation documentation were either missing or only obtained after the fact, and there was no evidence that residents were protected from potential further abuse during the investigative process.
Failure to Protect Residents During Abuse Investigation
Penalty
Summary
The facility failed to protect residents from further potential abuse during the investigation of an alleged abuse incident involving a nurse and a resident. According to the facility's abuse policy, there should be evidence that all investigative components are thoroughly investigated and that further abuse, neglect, exploitation, or mistreatment is prevented while the investigation is ongoing. However, the Director of Nursing (DON) confirmed that the alleged employee, an LPN, was not suspended or otherwise restricted from resident care during the investigation, as the DON believed nothing had happened. The LPN in question had access to all residents in the building while on shift, despite being formally assigned to half the building. The DON, who is a sibling of the LPN, stated that all disciplinary actions regarding the LPN were handled by the former Nursing Home Administrator (FNHA). The DON was made aware of the incident several days after it occurred and conducted interviews, but did not suspend the LPN during the process. The Nursing Home Administrator (NHA) later confirmed that there was no documentation of the initial investigation and only provided employee statements and an investigation summary after re-obtaining statements from staff. The facility's records showed that the LPN was not scheduled to work for several days following the incident, but this was due to the original schedule and not as a result of any suspension or protective measure.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by regulatory guidelines. According to the facility's own Abuse Policy, any reportable incident or allegation must be reported immediately or within 24 hours, with a follow-up investigation submitted within 5 working days. A review of an investigative summary revealed that the Director of Nursing (DON) was notified of an incident involving an LPN and two residents, where the LPN was observed speaking firmly and using a curse word in response to a resident. Staff interviews provided conflicting accounts, with one staff member recalling loud talking and another denying verbal abuse. The DON conducted interviews and documented findings but did not report the allegations to the State Agency, stating that nothing had happened. Further interviews revealed that the DON was aware of the incident and had a personal relationship with the LPN involved, which influenced the handling of disciplinary actions. The DON confirmed that the incident was not reported because they believed no abuse had occurred. The Nursing Home Administrator (NHA) also confirmed that there was no documentation of the investigation and acknowledged that the incident should have been reported to the State Agency. The failure to report the allegation had the potential to affect all residents in the facility.
Deficiencies in Food Labeling and Date-Marking
Penalty
Summary
The facility failed to ensure proper labeling and date-marking of food items, which is a requirement to prevent potential food-borne illnesses. During an initial kitchen tour, it was observed that large plastic bins containing thick-it, cornstarch, flour, and sugar were not dated with an open and use-by date. Additionally, four sealed plastic bags containing a red liquid were only marked with a received-by date and lacked any identification of the contents. Interviews with the Certified Dietary Manager (CDM) and Cook-B confirmed these labeling deficiencies. Further observations in the walk-in freezer revealed clear plastic bags of unidentified meat products and breaded food items, which were only labeled with received-by dates and lacked any additional identification. The facility also failed to adhere to the 7-day consumption or disposal requirement for ready-to-eat, time/temperature-controlled foods. During an observation, Cook-B was seen preparing a salad using lettuce, onion, shredded cheese, and pickles that were dated beyond the 7-day limit. Interviews with Cook-B and the CDM confirmed that these items were more than seven days old and should have been removed from the mobile salad station. These deficiencies in food labeling and date-marking had the potential to affect all 43 residents served by the facility's kitchen.
Non-Functional Ventilation System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation system was operational in the bathrooms of the 100, 200, and 300 wings, potentially affecting all 43 residents residing within the facility. A review of the facility's maintenance policy, last revised in December 2009, indicated that maintenance personnel are responsible for maintaining the building in compliance with federal, state, and local laws, regulations, and guidelines. During an observation on August 8, 2024, a strong odor of bowel movement was detected in the 100 wing. Further inspection revealed that the ventilation systems in rooms 101, 104, 111, 200, 300, and 301 were not functional, as they failed to draw a 1-ply square of toilet paper to the surface of the ventilation cover. An interview with the Administrator and Maintenance Personnel confirmed the non-functionality of the ventilation systems in these wings, affecting all residents.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding the use of enhanced barrier precautions (EBP) and personal protective equipment (PPE). In the case of Resident 3, who had a stage 4 pressure ulcer and a suprapubic urinary catheter, the facility's policy required staff to wear gloves and gowns during high-contact care activities. However, during an observation, a nurse aide assisted with wound care and repositioning without wearing a gown, despite being aware of the EBP requirements. This oversight was confirmed during an interview with the nurse aide. Additionally, the facility's staff did not follow proper hand hygiene protocols during urinary catheter care for Resident 40 and medication administration for Resident 12. A nurse aide failed to perform hand hygiene between glove changes and contaminated their clothing due to improper gown use during catheter care. Similarly, a registered nurse administered insulin to Resident 12 without changing gloves after touching potentially contaminated surfaces. These actions were confirmed through interviews with the involved staff members.
Failure to Monitor Blood Pressure in Resident on Hypertension Medication
Penalty
Summary
The facility failed to adequately monitor the blood pressure of a resident who was taking medications for hypertension. According to the facility's Admission Check Off List, staff were required to put an order in for weekly vital signs for residents on blood pressure medication. However, a review of Resident 2's records revealed that there was no order for weekly blood pressure monitoring, despite the resident being on Amlodipine Besylate and Lisinopril for blood pressure management. The resident's blood pressure was not consistently checked on a weekly basis, as evidenced by gaps in the recorded blood pressure readings over several months. The deficiency was confirmed through interviews with the Director of Nursing (DON), who acknowledged that the facility did not have an order for weekly blood pressure monitoring for Resident 2, contrary to the facility's protocol. The resident experienced significant fluctuations in blood pressure, including a critically low reading that led to hospital admission. Despite these fluctuations, the facility did not implement the required weekly monitoring, which was a clear deviation from the established care protocol for residents on hypertension medication.
Pharmacist Fails to Identify Medication Irregularity
Penalty
Summary
The facility failed to ensure that a licensed pharmacist identified irregularities during the monthly medication regimen review (MRR) for a resident. The deficiency was identified for one resident out of a sample of five, in a facility with a census of 43. The facility's policy on Medication Regimen Reviews, last revised in April 2007, lacked information on identifying irregularities in accordance with regulatory requirements. The resident in question was admitted with diagnoses of dementia, Alzheimer's disease, and Major Depressive Disorder, and had a severe cognitive impairment as indicated by a Brief Interview for Mental Status score of 4/15. The resident had an order for PRN Ativan starting in February 2024, which did not include a stop date. Despite this, the pharmacist's monthly reviews from March to August 2024 did not identify any irregularities. An interview with the pharmacist confirmed that the absence of a stop date for Ativan should have been recognized as an irregularity. This oversight indicates a failure in the medication review process, as the pharmacist did not identify the irregularity in the resident's medication order during the specified period.
PRN Psychotropic Medication Lacked Stop Date
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, specifically Ativan, prescribed to a resident had a stop date, which is a requirement according to their policy. The policy mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration, typically 14 days. If an extension is needed, the attending physician must document the rationale and indicate the duration in the resident's medical record. However, in this case, the PRN Ativan order for the resident, who was admitted with dementia, Alzheimer's disease, and Major Depressive Disorder, did not have a stop date. The deficiency was identified during a record review and confirmed through an interview with the Director of Nursing, who acknowledged that the PRN Ativan order lacked a stop date. The resident in question had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 4/15 on their quarterly Minimum Data Set assessment. The absence of a stop date for the PRN Ativan order was a clear deviation from the facility's policy, which requires such orders to have a specified duration or stop date.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mitchell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare And Nursing Center | 8.2 mi | ★★★★★ | 13 | 0 |
| Northfield Retirement Communities Care Center | 9.2 mi | ★★★★★ | 2 | 0 |
| Heritage Estates | 10.7 mi | ★★★★★ | 0 | 0 |
| Goshen Healthcare Community | 22.5 mi | ★★★★★ | 1 | 0 |
| Chimney Rock Villa | 27.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.