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
A resident who required extensive help with personal hygiene had repeated findings of food debris in the wheelchair frame, seat, and armrest, along with eggs, crumbs, and other food in the lap crease of the shirt. The resident’s care plan directed staff to keep the environment clean, and the facility’s wheelchair cleaning schedule showed missing or inconsistent documentation for the resident’s wheelchair cleaning, despite the DON stating wheelchairs were expected to be cleaned weekly and as needed when visibly soiled.
The facility failed to notify a resident’s responsible party of the bed hold when the resident was transferred out, and failed to include another resident’s transfer/discharge on the monthly ombudsman report. Record review and staff interview showed the bed hold notice was given to the resident and mailed later to the family, but there was no documentation that the responsible party was notified at the time of transfer. The monthly Action Summary sent to the ombudsman also omitted a resident who was hospitalized and later discharged to another care facility.
Improper catheter care and infection control practices were observed for a resident with a Foley catheter and a history of UTI. A nurse aide placed supplies directly on the bed without a clean barrier, used the same gloved hand to handle clean wipes after cleansing stool, and then cleaned the catheter tubing without changing gloves or performing hand hygiene. The ICP confirmed the aide did not use proper technique.
Resident room walls were observed with moisture, black/gray staining resembling mildew or mold-like substance, bubbling paint, cracks, gouges, and dirty vents in multiple rooms, including B-2, B-4, B-6, B-8, B-10, and B-12. The Tel's record review showed no reports about the wall conditions for the past 6 months, and the ADM stated the moisture had been present for a while and had not previously been brought to the ADM and Maintenance Director's attention.
A resident with schizophrenia, depression, and later severe cognitive impairment repeatedly pursued another resident, with records showing obsessive, aggressive, and sexually inappropriate behaviors, including yelling, cursing, hovering, and distress when the other resident was unavailable. The other resident, who had Alzheimer’s disease and later severe cognitive impairment, told staff the resident was always there and that they wanted nothing to do with the resident. The DON and SSD confirmed the pursuit continued and that no assessment had been completed to ensure intimacy rights and self-determination while protecting both residents from potential abuse.
A resident with dementia, severe cognitive impairment, wandering, and behavioral symptoms had a care plan with anxiety-related interventions, but staff did not consistently provide meaningful behavior management services. After a resident-to-resident altercation caused a superficial skin break, staff identified activity engagement when the resident entered others’ personal space, yet this intervention was not added to the care plan. Observations showed the resident wandering into rooms and approaching others without resident engagement activities in place, while staff mainly relied on separation, snacks, toileting, or redirection.
Soiled wheelchair and clothing not kept clean
Penalty
Summary
The facility failed to ensure the resident environment was free of soiling and debris and cleaned consistently with facility practices for one resident who required extensive assistance with personal hygiene. The resident’s care plan directed staff to keep the environment clean and to ensure an environment conducive to comfort. During observations, the resident’s wheelchair was found to have food in between the wheelchair frame, seat, and armrest, and the resident also had eggs, crumbs, and other food items sitting in the lap crease of the shirt. The wheelchair remained soiled across multiple observations, including repeated findings of food in the wheelchair frame and armrest area even after the resident’s shirt had been cleaned. An interview with a nurse aide revealed that wheelchair cleaning was part of night shift duties and that the facility used a Nightshift binder with a wheelchair cleaning schedule. Record review of the cleaning schedule showed multiple missing forms for several date ranges and inconsistent documentation for the resident’s wheelchair cleaning, with some entries blank, some marked with a line through them, and some initialed. The DON stated the facility expected all resident wheelchairs to be cleaned weekly and as needed when visibly soiled, and later stated the resident’s wheelchair had been deep cleaned and daily checks had been initiated.
Failure to Notify Responsible Party of Bed Hold and Report Resident Transfer to Ombudsman
Penalty
Summary
The facility failed to notify a resident’s responsible party of the bed hold policy at the time the resident was transferred from the facility for an emergency room transfer. Record review showed the resident was sent out with a copy of the bed hold policy, and later documentation indicated the policy was mailed to the resident’s family/responsible party on the next business day. However, there was no documentation in the resident’s record showing that the family or responsible party was notified of the bed hold when the transfer occurred. The Social Service Director confirmed that the facility’s process was to give the notice to the resident at transfer and mail it to the responsible party afterward, and the Regional Administrator confirmed there was no documentation showing the responsible party was notified at the time of transfer. The facility also failed to include a resident’s transfer or discharge on the monthly report sent to the ombudsman. Record review showed the resident was admitted to the hospital and later discharged from the facility after being admitted to another care facility from the hospital. The facility’s monthly Action Summary, which the Social Service Director identified as the report sent to the ombudsman, did not list this resident’s transfer or discharge during the reporting period. The Social Service Director confirmed the resident should have been included on the report but was not.
Improper Catheter Care and Infection Control Practices
Penalty
Summary
Catheter care was not performed in a manner to prevent cross contamination and infection for a resident with a Foley catheter and a history of urinary tract infection. The resident’s care plan directed staff to provide catheter care every shift using proper technique. During observation, a nurse aide placed disposable wipes, an incontinence product, and gloves on the foot of the resident’s bed without first placing a clean barrier on the bed. The resident was incontinent of a bowel movement, and the nurse aide used a wipe to begin cleansing the resident’s skin. The aide then used the same soiled, gloved hand to obtain additional wipes from the container and finished cleansing the visible stool. Without changing gloves or performing hand hygiene, the aide grasped the resident’s catheter with the gloved hand and used a disposable wipe to cleanse the tubing, repeating the action twice with the same wipe. The nurse aide later confirmed the supplies had been placed directly on the bed, that gloves were not changed after cleansing the resident’s soiling, and that they were unsure whether it was acceptable to use the same area of the disposable wipe on the catheter tubing. The infection control nurse confirmed that a clean barrier should have been used, gloves should have been removed with hand hygiene performed after cleansing the visible soiling, and a separate area of the disposable cloth or a new cloth should have been used for each wipe down of the catheter.
Resident Room Walls Found Moist, Stained, and Damaged
Penalty
Summary
Resident room walls were not kept free from moisture, black/gray staining, gouges, bubbling paint, and dirt in multiple rooms. On 5/27/26 at 11:00 AM, an observation found room B-2 with dirty vents and a small gouge in the drywall; room B-4 with an outside wall that was moist and had a grayish stain about 1 foot by 1 foot resembling mildew or a mold-like substance; room B-6 with a moist outside wall, a black/gray substance resembling mildew, and several bubbles and cracks in the paint; room B-8 with an outside wall that felt moist to touch and had a blackish/gray substance about 2 feet by 2 feet resembling mildew or a mold-like substance; room B-10 with streaks and stains going down the outside wall; and room B-12 with cracks in the drywall, streaks down the wall, and bubbling paint. A record review of the Tel's program showed no report regarding the resident walls for the past 6 months. During an environmental tour on 5/28/2026 at 1:00 PM with the Administrator and Maintenance Director, the same wall conditions were confirmed in rooms B-2, B-4, B-6, B-8, B-10, and B-12. In an interview at that time, the Administrator stated the moisture on the walls in the resident rooms had been there for a while and should have been reported by staff who see the wall daily, and also stated this was the first time the walls had been brought to the Administrator and Maintenance Director's attention.
Failure to Protect Two Residents From Adverse Behaviors
Penalty
Summary
The facility failed to ensure that two residents were protected from adverse behaviors by another resident. The deficiency was cited under the requirement to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect. Survey review found that Resident 5 and Resident 10 were involved in a relationship that was initially described in the care plans as consensual, with both residents’ POAs aware of it, but the record also showed repeated episodes of escalating, obsessive, and aggressive behavior by Resident 5 toward Resident 10. Resident 5’s record showed multiple incidents of yelling, cursing, pacing, throwing or slamming a walker, wandering into other residents’ spaces, and becoming distressed when unable to locate Resident 10. The resident was documented as obsessive toward Resident 10, repeatedly seeking the resident out, becoming angry when Resident 10 was not available, and at times hovering over Resident 10 until the resident became anxious. Resident 5 also had episodes of sexually inappropriate behavior, including an order for estradiol after sexually inappropriate behaviors were documented, and later had a BIMS score of 5 indicating severe cognitive impairment. The resident’s diagnoses included prostate cancer, anemia, heart failure, diabetes, depression, schizophrenia, and insomnia, and the resident was receiving antipsychotic, antidepressant, and antianxiety medications. Resident 10’s record showed diagnoses of atrial fibrillation, hypertension, and Alzheimer’s disease, with the resident initially assessed as cognitively intact and later documented as severely impaired. The care plan also described the relationship as consensual and noted that the POA was aware and fine with it. However, Resident 10 told staff that Resident 5 was always there and that the resident wanted nothing to do with Resident 5. During interview, the DON and SSD confirmed that Resident 5 continued to pursue Resident 10, that Resident 10 initially did not want the relationship, and that no assessment had been completed of either resident to ensure rights to intimacy and companionship or self-determination while also protecting against potential abuse.
Failure to Implement Behavior Interventions for a Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with dementia and behavioral symptoms. The resident’s MDS documented long- and short-term memory problems, severe cognitive deficits, rejection of care, wandering, and physical and verbal behaviors, along with diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, depression, and psychotic disorder. The care plan identified behaviors including constant worry, repeated voicing of concerns, crying, restlessness, pacing, attention seeking, verbal statements of nervousness, looking for parents, and fear, with interventions such as reassurance, redirection, 1:1 bedside activities, and environmental changes during anxiety. The facility investigation report showed the resident had an altercation with another resident after invading that resident’s personal space, and the other resident made physical contact that caused a superficial break in the skin. After the incident, staff separated the residents and identified that staff would engage the resident in an activity when the resident began consistently entering other residents’ personal spaces. However, there was no evidence that this intervention was added to the resident’s care plan, and staff later confirmed that no new intervention had been implemented for the resident-to-resident incident. Survey observations showed the resident wandering, entering other residents’ rooms, approaching residents in the sitting area, and spending time without any documented resident engagement activity in place. Staff were observed moving the resident back to the recliner or redirecting the resident, but no independent activities were offered during several observations. Interviews with nursing assistants, medication aides, social services, and the DON showed the unit staff generally relied on separating residents, offering snacks, toileting, or calming the setting, and stated that unit staff did not provide activities, while activity staff only did 1:1 activities a few times per week.
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Compliance trends in Nebraska
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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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