Citations in Nebraska
Statistics, citations and compliance trends for long-term care facilities in Nebraska.
Statistics for Nebraska (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Nebraska
Food portions were not served per recipe directions when a cook prepared sandwiches, pureed items, cake, and side items by estimation instead of measured amounts. The cook used tongs to add unmeasured meat, onions, and cheese to buns, served visibly different cake portions, and confirmed there were not enough pickles for all residents. The cook stated the portions were “eye balled” and that the spoons were inconsistent.
Kitchen Food Storage and Hand Hygiene Failures: Surveyors observed multiple expired, undated, unlabeled, and unsealed food items in dry storage, coolers, and freezers, and the RD confirmed staff were only marking opening dates rather than all required food dates. During meal prep, Cook-I repeatedly failed to perform hand hygiene before and after glove use and handled food, utensils, equipment, and surfaces with the same gloves or bare hands while preparing resident meals.
NA Training and Dementia Education Deficiency: The facility failed to ensure an NA received the required 12 hours of annual education and dementia management training as required by the Facility Assessment. Records showed the NA had only 10.15 hours of continuing education, no documented dementia training, and did not attend staff in-services or nursing meetings; the FA and DON confirmed the missing training documentation.
The facility failed to document and offer nonpharmacological treatment options when obtaining consent for psychotropic medications for several residents. A resident with PTSD, anxiety, and depression; a resident with severe cognitive impairment and dementia; and two residents with dementia-related behaviors received antipsychotic, antianxiety, and/or antidepressant medications, and consent forms were completed, but the records did not show that alternate treatment interventions were presented. The DON confirmed the facility had no evidence that these options were provided with the psychotropic medication consents.
Failure to Test Symptomatic Residents for COVID-19: The DON confirmed the facility was not testing all residents with respiratory symptoms for COVID-19 and was relying on physician direction or surveyor request. One resident with dementia, diabetes, and HTN had fatigue, cough, and lethargy before a COVID test was finally obtained; another resident with CAD, HTN, kidney disease, and vascular disease had a prolonged cough, congestion, weakness, and fatigue without evidence of testing; a third resident with severe cognitive impairment, HF, kidney disease, diabetes, and dementia had cough, sore throat, low O2 sat, fever, wheezing, and lethargy before testing was done.
A resident’s CCP was not updated after an oxygen order changed from 3 LPM to 4-5 LPM, and two other residents’ CCPs did not reflect self-administration of medications. One resident with schizophrenia had multiple meds ordered for bedside storage or unsupervised self-administration, but the CCP had no related focus or interventions. Another resident with dementia and diabetes was observed self-administering insulin even though the CCP only addressed staff administration.
Food Portions Not Measured Per Recipe
Penalty
Summary
The facility failed to serve foods according to the recipe serving sizes to ensure residents received the correct amounts of protein and other nutrients. The cited recipe for the evening meal specified measured portions for the steak, onion, and cheese submarine sandwiches, potato wedges, pickle spears, and lemon poke cake, but during meal preparation the cook did not measure the meat, onions, cheese, or other components as directed. The cook stated they were preparing 30 servings and had 2 lbs, 2 oz of onions, but then weighed all 4 onions to a total of 2.5 lbs and began slicing them, placed the onions in the refrigerator, and later added an unmeasured amount of margarine and onions to the skillet. During meal service, the cook repeatedly served food by estimation rather than by the recipe portions. The cook removed frozen meat, cooked it, and then used tongs to place an unmeasured amount of meat and onion mixture into each bun, with a visible difference in the amount going into each sandwich. The cook also used the same tongs to add an unmeasured amount of cheese to each bun. For residents who required pureed foods, the cook added unmeasured amounts of the meat, onion, and cheese mixture to blender cups and pureed the food, including adding an unmeasured amount of milk and liquid grease. The cook also plated unmeasured amounts of the pureed meat and onion mixture onto residents’ trays. The cook further prepared and served desserts and side items without consistent portioning. The cake was sliced into unmeasured servings, with each serving visibly different in size, and some portions were pureed with milk. The cook confirmed there were 2 pureed diets, 1 chopped diet, and 1 bite sized diet, and also confirmed there were not enough pickles for all residents and no extras were available. At 6:04 PM, the cook stated the meat and onion mixture and cheese were not measured and that they had “eye balled” the sandwiches with the tongs, adding that the spoons were inconsistent and they thought the recipe said to use the tongs.
Kitchen Food Storage and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure that dietary personnel used hand hygiene as required in the kitchen and failed to ensure that foods in the kitchen were dated, labeled, and discarded when appropriate. During an initial kitchen tour, surveyors observed multiple food items with expired, missing, or incomplete date markings, including muffin mix past its best-buy date, syrup, pudding, canned fruit, tuna, bread, soft serve mix, and multiple frozen items in the walk-in and standing freezers. An unsealed container of cookies was also observed, and the Registered Dietician confirmed the expired foods, undated products, and unsealed items. Record review showed the facility had written expectations for stock rotation and date marking, including use of stickers for dating foods and discarding items based on manufacturer dates or within four days of opening, whichever came first. The RD stated that kitchen staff were supposed to use stickers for dating all foods, but also confirmed that staff only marked the opening date of items. The observations showed numerous foods stored in the kitchen without required dates or labels, and some items were beyond their best-by dates or left unsealed. During evening meal preparation, Cook-I repeatedly handled food and kitchen items without performing hand hygiene at required times and used the same gloves across multiple tasks. Cook-I peeled, chopped, labeled, refrigerated, and plated foods while touching glasses, using a rag, opening refrigerator doors, handling utensils, and transferring food without changing gloves or cleaning hands. Cook-I also used bare hands to handle food and equipment, including touching the blender cup lid, spooning pureed cake into bowls, and placing a piece of meat into a hot dog bun after it fell from tongs. The facility policy stated that hand hygiene must be performed before donning gloves and immediately after removing gloves, and Cook-I confirmed they did not realize they were touching items such as their glasses with gloved hands.
NA Training and Dementia Education Deficiency
Penalty
Summary
The facility failed to ensure that Nurse Aides (NAs) received at least 12 hours of yearly education and failed to follow its Facility Assessment, which required dementia management training for NAs. Record review of the Facility Assessment showed that staff training, education, and competencies were to include no less than 12 hours per year for NAs and dementia management training among other subjects. The deficiency affected 1 of 1 NAs sampled in a facility with a census of 27. Record review of the Training Hours document for NA-A showed that the NA, hired on 6/11/2024, had only 10.15 hours of continuing education documented from 6/11/2025 to 6/11/2026, and no dementia management training was listed. Nursing services monthly meeting records showed that NA-A did not attend and had no further education through nurse staff meetings. The Facility Administrator stated that past nursing in-services were reviewed and NA-A did not attend any staff in-services, and the Director of Nursing confirmed that the total continuing education hours were not equal to or greater than 12 hours and that no dementia management training was documented.
Failure to Inform Residents of Nonpharmacological Options for Psychotropic Medications
Penalty
Summary
The facility failed to fully inform residents and/or their resident representatives by not documenting and offering nonpharmacological treatment options when obtaining consent for psychotropic medications. The deficiency involved 4 of 5 sampled residents, including residents with diagnoses such as dementia, anxiety, depression, PTSD, stroke, and severe cognitive impairment. Facility policies stated that residents and/or representatives would be educated on medications and that consent forms would be completed with new psychotropic orders and dose increases, but the records reviewed did not show alternative nonpharmacological interventions were presented with the consents. Resident 4 was cognitively intact, independent with several activities of daily living, and had diagnoses including diabetes, stroke, anxiety, depression, and PTSD. The resident received aripiprazole, buspirone, fluoxetine, and trazodone, and consent forms were completed for each medication. Resident 25 had severe cognitive impairment, required staff assistance with dressing, toileting, transfers, and hygiene, and had diagnoses of dementia, anxiety, and depression. The resident received bupropion and venlafaxine, and consent forms were completed for both medications. For both residents, the record contained no evidence that nonpharmacological treatment options were documented and offered. Resident 21 had severe cognitive impairment, delusions, and other behaviors 1-3 days weekly, with diagnoses of dementia, anxiety, and depression, and received mirtazapine, citalopram, quetiapine, and lorazepam. Resident 1 had severe cognitive impairment, rejected care, wandered 1-3 days in the prior 7 days, required assistance with hygiene, dressing, and bathing, and received lorazepam and quetiapine for anxiety and behavior disturbance associated with dementia. For both residents, consent forms were present for the psychotropic medications, but there was no evidence that alternative nonpharmacological treatment intervention options were documented and offered. The DON confirmed during interview that the facility did not have evidence that such alternatives were provided when obtaining consent.
Failure to Test Symptomatic Residents for COVID-19
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when it did not test residents for COVID-19 after they developed signs and symptoms of respiratory illness. The facility policy stated that residents should be tested when symptoms such as fever or chills, cough, shortness of breath, fatigue, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea were present. During interview, the DON confirmed the facility was not testing all residents with respiratory symptoms for COVID-19 and that some testing was done only at the physician’s direction or after surveyor request. Resident 1 had severe cognitive impairment, dementia, diabetes, and hypertension, and was noted to have fatigue, a nonproductive cough, increased lethargy, and a temperature of 99.1. The resident was not tested for COVID-19 when these symptoms were first documented; a COVID-19 antigen rapid test was not given until after surveyors requested evidence of testing, and the result was negative. The DON confirmed the resident was not tested when the respiratory symptoms were present. Resident 19 had coronary artery disease, hypertension, kidney disease, and vascular disease, and was not up to date on the COVID-19 vaccine. The resident developed a harsh cough, runny nose, chest congestion, coarse lung sounds, weakness, fatigue, and ongoing cough symptoms over an extended period, but there was no evidence of COVID-19 testing during the illness. Resident 26 had severe cognitive impairment, hypertension, heart failure, kidney disease, diabetes, and dementia, and presented with congested cough, sore throat, head and chest congestion, low oxygen saturation of 88%, fever up to 100.5, wheezing, weakness, lethargy, and coarse lung sounds. Although the resident continued to be monitored and later received medications, COVID-19 testing was not performed until after surveyor inquiry, and the DON confirmed the resident was not tested when respiratory illness symptoms were observed.
CCPs Not Updated for Oxygen Orders and Self-Administration Needs
Penalty
Summary
The facility failed to keep the Comprehensive Care Plan (CCP) updated for a resident with malignant neoplasm of the left bronchus or lung, chronic obstructive pulmonary disease, and chronic respiratory failure. The resident’s CCP still listed oxygen at 3 liters per minute via nasal cannula with a start date of 10/23/2025, while the active physician’s order reviewed on 7/21/2026 directed continuous oxygen via nasal cannula at 4 to 5 liters, with a start date of 5/23/2026. The Clinical Nurse Manager confirmed on 8/3/2026 that the CCP had not been updated when the oxygen order changed and should have been. The facility also failed to include self-administration of medications in the CCPs for two residents. One resident with schizophrenia had active orders for several medications that could be kept at bedside or were marked for unsupervised self-administration, including cough drops, Vicks VapoRub, saline mist, and Abreva, and was observed with cough drops on the bedside table while stating the medication could be kept in the room. The CCP contained no focus, goal, or interventions related to self-administration, and the CNM confirmed this omission. Another resident with unspecified dementia and type 2 diabetes mellitus had an order for insulin lispro injections, no order for self-administration, and a CCP that addressed insulin-dependent diabetes only with medication administration by staff; however, the resident was observed being handed an alcohol wipe and syringe and then self-administering insulin.
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Compliance trends in Nebraska
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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