Licensure Reference Number: 175 NAC 12-006.02 and 175 NAC 12-006.05(9) Based on record review and interviews, the facility failed to identify an allegation of staff to resident abuse and failed to put measures in place to protect the resident from further potential abuse for one current sampled resident (Resident 5). The facility census was 39 with 15 current sampled residents. Findings are: Interview with Resident 5 on 6/15/22 at 4:02 PM, revealed on May 21, 2022, NA (Nursing Assistant)-A was performing peri care after the resident had a bowel movement (bm) and had applied pressure on resident's lower abdomen with NA-A's arm/elbow. Resident 5 disclosed that NA-A had placed three fingers and a wipe soiled with feces in Resident 5's vagina. …
F609 citations in Nebraska
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nebraska cites F609 more often than its own record predicts
1.75 times the share F609 takes of citations nationally.
Of every deficiency written in Nebraska in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nebraska surveyors wrote
F609 findings written in Nebraska, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that resident abuse resulting in injury was investigated for 1 resident (Resident 87) and the facility failed to ensure that misappropriation of resident property was investigated for 1 resident (Resident 86). Based on record review and interview, the facility failed to ensure incident investigations were submitted to the state agency within 5 working days. This affected 5 residents (Residents 14, 40, 69, 86, and 87) of 10 residents reviewed. The facility census was 123. Findings are: A) Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. …
Licensure Reference Number 175 NAC 12-006.02(H)Adult Protective Services Act, Nebraska Revised Statute 28-372Based on record review and interview the facility failed to report suspicion/allegation of misappropriation and abuse to the state agency within the required time frames. This affected 2 of 2 residents (Residents 41 and 66). The facility census was 54.Findings are:A record review of a facility policy titled, Abuse, Neglect and Exploitation dated and revised on 7/22/25 revealed; it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. V. …
The short window
Recent years
| Year | Share of Nebraska citations | vs expected |
|---|---|---|
| 2023 | 2.82% | 1.43× |
| 2024 | 3.07% | 1.34× |
| 2025 | 4.28% | 1.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nebraska surveyors cite →
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