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
Unsafe Resident Room Temperatures and Heat Injury: A resident with COPD, PVD, HTN, and moderate cognitive impairment was found in a very warm room with no fan or cooling device present and later had a temperature of 103.7°F after becoming confused and weak in the bathroom. Staff reported that room AC had not been working for weeks, the chiller needed recharging, and hydration passes were not increased despite hot weather. Other rooms were also warm, and staff confirmed they had not received education on recognizing or preventing heat injury.
Incomplete informed consent for psychotropic medications: The facility failed to ensure a resident or representative was fully informed before psychotropic meds were started or increased. Records for multiple residents showed consent forms that omitted dose, frequency, symptoms being treated, potential adverse effects, and alternative or non-pharmacological options for meds such as Alprazolam, Zoloft, Trazodone, Seroquel, Ativan, Cymbalta, Rexulti, Wellbutrin, Paroxetine, Lorazepam, Quetiapine, and Sertraline. The DON confirmed several consents were incomplete or missing.
Failure to Identify Causes and Individualize Fall Interventions: A resident with severe cognitive impairment, incontinence, and multiple psychoactive meds had repeated falls in the room and bathroom area. The facility often documented no causal factors or used limited interventions such as a reminder sign, med review, video monitoring, and alarms, while not addressing issues noted in the events such as toileting needs, feces in the bathroom, poor lighting, and refusal to wear gripper socks or shoes.
Incorrect Therapeutic Diet Served to a Resident with Dysphagia: A resident with pneumonitis, dementia, and dysphagia was ordered a minced and moist diet with mildly thick liquids, but was served regular chicken at lunch instead. The resident choked in the dining room, staff performed the Heimlich maneuver, and the resident was sent to the hospital after choking on a large piece of chicken.
A dietary service failure occurred when staff served residents portions that did not match approved recipe serving sizes. During meal service, aides used #16 2-oz scoops for rice, refried beans, and pureed taco items, resulting in servings that were only half of the required amount for rice and beans and far below the required portion for pureed tacos. In a satellite kitchen, staff reported using the required scoop, but only #12 and one #16 scoop were available, and an aide stated the same scoop was being used for all food items.
Kitchen staff failed to date and properly label multiple stored food items, including several expired products, and surveyors also observed improper hand hygiene and food handling practices. The DM was seen washing hands for too short a time, working with an empty soap dispenser, handling food with gloves and a knife in a way that raised cross-contamination concerns, and entering a bathroom while wearing a kitchen apron; facility policy required handwashing before and after glove use and food handling.
Unsafe Resident Room Temperatures and Heat Injury
Penalty
Summary
The facility failed to develop and implement a plan to maintain safe temperatures in resident rooms. Survey findings showed that the resident room environment was warm, with the resident’s room window open and hot air blowing in, and no fan or other cooling device present in the room. The facility Administrator confirmed that the building was warm because the chiller for the resident room air conditioning units needed to be recharged, and there was no definitive time for completion. The Administrator also confirmed that the facility had not provided staff education on monitoring residents for heat injury, preventing heat injury, increasing hydration, or responding to heat injury. The affected resident was over 65 years old and had diagnoses including peripheral vascular disease, COPD, and hypertension. The resident’s record showed moderate cognitive impairment with a BIMS score of 11. On the evening of the incident, a nurse entered the resident’s room to give bedtime medications and found the room very warm. The resident was later found sitting on the toilet with the upper body leaning to the left, head down against the wall, appearing confused and very warm. The resident’s temperature was 103.7 degrees Fahrenheit, and cold compresses were applied. The resident’s condition was reported to the POA and hospice. Additional observations showed that other resident rooms were also warm, including a room measured at 78.4 degrees Fahrenheit with the resident stating the air conditioner did not work and had not worked for about 2 years. A nurse aide confirmed that resident room air conditioning had not been working for several weeks, and the facility had not increased water passes despite the hot weather. The Maintenance Supervisor stated that the 100/200 hall chiller condenser had needed recharging since the cooling season began and that there were three units not working. The resident’s functional status also declined after the incident, with records showing a shift from independent toilet transfers and mobility to needing increasing levels of assistance over the following days.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure residents were fully informed and understood their health status, care, and treatments before psychotropic medications were administered or increased. The deficiency involved Residents 4, 5, 9, 18, and 27, and the record review showed that informed consent forms often did not include the current dose, frequency, symptoms being treated, potential effects or adverse effects, or alternative/non-pharmacological treatment options. The facility policy required residents or their representatives to be informed in advance of the benefits, risks, and alternatives for psychotropic medications, including black box warnings for antipsychotics, and to document that this information was provided. For Resident 9, the record showed multiple new or changed orders for Alprazolam and other psychotropic medications, but there was no documentation that the resident or representative was informed of the risks, benefits, or alternatives before those orders were implemented. Several consent forms for Zoloft, Alprazolam, Trazodone, Seroquel, and a one-time Alprazolam dose lacked documentation of symptoms, adverse effects, and non-pharmacological interventions. The DON confirmed that consents were not completed for several Alprazolam orders and that the forms did not include non-pharmacological interventions attempted, symptoms displayed, or potential effects or adverse effects. For Resident 4, the record showed psychotropic medication consents for Cymbalta, Rexulti, Ativan, and Wellbutrin, but the forms did not identify how often the medications were to be given, the dose in some cases, the symptoms being displayed, potential effects or adverse effects, or non-pharmacological interventions attempted. The DON confirmed these consent forms did not contain the required information. For Resident 18, consent forms for Trazodone, Zyprexa, Ativan, and Zoloft similarly lacked dose, frequency, symptoms, adverse effects, and non-pharmacological interventions, and the DON confirmed the omissions. For Resident 5, the record showed consent for Paroxetine without an alternative treatment plan and no informed consent completed for Lorazepam. For Resident 27, consent forms for Trazodone, Lorazepam, Quetiapine, and Sertraline did not state the dose and did not include an alternative treatment plan, and the DON confirmed the consents did not include the current dose ordered and/or alternative treatment plans.
Failure to Identify Causes and Individualize Fall Interventions
Penalty
Summary
The facility failed to identify causal factors for repeated falls and failed to develop fall prevention interventions based on those causal factors for a resident with severe cognitive impairment, dependence on staff for all cares, bowel and bladder incontinence, and diagnoses including non-Alzheimer's dementia, fractures, malnutrition, depression, and anxiety. The resident was receiving antipsychotic, antidepressant, and opioid medications. The facility’s fall prevention program required assessment of fall risk, monitoring for changes in cognition, gait, balance, and ability to rise/sit, and use of individualized interventions based on the resident’s level of risk. The resident had multiple falls in the room and bathroom area. After one fall, the resident was found on the floor between the bed and dresser and the only documented intervention was a sign on the wall reminding the resident to call for help, despite the resident’s severe cognitive impairment. After another fall, the resident was found on the floor in front of the bathroom door; the resident said the walker had been moved, but the walker was not near the fall location, and the only listed intervention was a medication review. Another fall occurred when the resident was found on the floor between the bed and bathroom with feces observed on the brief and in the bathroom, yet there was no evidence the facility reviewed or revised the bowel and bladder program. Additional falls showed the same pattern of incomplete assessment and intervention. The resident was found on the floor between the bed and dresser when no lights were on in the room and the resident was barefoot, but the facility did not address the lighting or the resident’s refusal to wear gripper socks or shoes. After another fall, the resident was found on the floor by the bed after removing gripper socks and stating the resident was on the way to the bathroom; the facility added a video monitor and alarms, but did not address the toileting schedule or the refusal to wear gripper socks. The DON confirmed that no causal factors were identified for several of the falls and that the interventions used did not address the resident’s cognition, toileting needs, lighting, or footwear issues.
Incorrect Therapeutic Diet Served to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the correct therapeutic diet for one resident who had been admitted with pneumonitis due to inhalation of food and vomit, dementia, and dysphagia. The resident’s care plan identified a nutrition focus with interventions for a general diet, minced and moist texture, and mildly thick liquids. Physician orders showed the resident had been admitted on a pureed diet and advanced with speech therapy to minced and moist on 5/20/26. On 6/7/26, the resident choked in the dining room and staff performed the Heimlich maneuver before the resident was sent to the hospital. The hospital history and physical documented that the resident had been choking on a piece of chicken approximately 8 centimeters long. The facility’s menu for that day listed baked chicken for lunch, and interviews with the Nutritional Culinary Director and the DON confirmed the resident was served regular chicken instead of the ordered minced and moist diet.
Incorrect Portion Sizes Served During Meal Service
Penalty
Summary
The facility failed to ensure residents were served the approved menu serving sizes. Record review showed that facility policies stated residents would receive diets ordered by their physicians and that menu selections were to be approved by a qualified dietitian. The recipes reviewed specified serving sizes for multiple menu items, including pureed beef soft tacos, Spanish rice, pureed Spanish rice, refried beans, pureed refried beans, lasagna, pureed lasagna, breadsticks, Caesar salad, chopped or soft chilled steamed vegetables, pureed chilled steamed vegetables, fresh fruit cup, pureed soft canned fruit, crispy beef tacos, beef soft tacos, shredded lettuce and diced tomatoes, paprika rice, seven up cake, and pureed seven up cake. During observation in the kitchen, dietary staff used blue handled #16 dishers, which were confirmed by the Dietary Manager to be 2-ounce scoops, to portion food for multiple residents. For residents receiving rice and refried beans, staff served 1 scoop of each item, which was only half of the 4-ounce serving size listed in the recipes. For residents receiving pureed tacos, staff served 1 scoop, which was far less than the 10.68-ounce portion required by the recipe. This occurred for residents receiving both regular and pureed meals, including residents served tacos, rice, and refried beans from the steam table. The Dietary Manager confirmed that the scoops used were the wrong size to provide the amounts directed by the menu recipes and stated that 2 scoops of pureed taco should have been served because 1 scoop was not enough. The manager also stated that a chart with disher sizes is usually posted in the kitchen but was not present. In a separate satellite kitchen, dietary staff stated they used the required scoop for the meal, but all available service scoops were green #12 scoops and one blue #16 scoop. A dietary aide stated the green 1/3 cup scoops were for all food items and the blue 1/4 cup scoop was for residents who do not eat a lot of food. The Dietary Manager later stated that dietary aides were not certain which scoops to use during service and that training was needed to get everyone on the same process of serving.
Kitchen Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to date and properly label multiple food items stored in the kitchen. During an initial kitchen tour, surveyors observed numerous items without required open, use-by, received, best-by, or expiration dates, including chicken base, baking soda, cornbread mix, biscuit mix, ketchup, mayonnaise packets, dill pickle relish, miracle whip, banana pudding, apricot halves, apples, cherry pie filling, bread, rolls, buns, almond milk, and ice cream mix. Surveyors also observed ceiling damage in the kitchen, including water staining on multiple ceiling panels and a ceiling tile with a hole. The Dietary Manager confirmed the expired dates on the listed items and discarded them. Surveyors also observed improper hand hygiene and food handling practices by the Dietary Manager and Dietary Aid. The Dietary Manager performed hand hygiene for only 3 seconds before stating soap was unavailable at the sink, and the soap dispenser was observed empty. After refilling the dispenser, the Dietary Manager and the Dietary Aid performed hand hygiene for 15 seconds and 12 seconds, respectively. Later, the Dietary Manager prepared vegetables, washed hands for 10 seconds, donned gloves, cut through butter with the wrapper still on, removed the wrapper, and used the same knife to cut the butter into smaller chunks and add them to the vegetable basins. The Dietary Manager then removed gloves and washed hands for 13 seconds. The Dietary Manager was also observed walking into the bathroom with a kitchen apron on. The Dietary Manager stated they should wash their hands for probably 30 seconds, and the facility policy required handwashing before and after glove use and food handling, with soap-and-water handwashing for a minimum of 15 seconds.
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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 1 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 1-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 1 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 1 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 1 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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