Licensure Reference Number 175 NAC ,d+[DATE].02(8) Based on observations, interviews, record reviews and review of policy and procedures, it was determined the facility failed to initiate an investigation for injuries of unknown source for two (Residents 16 and 46) of two sampled residents reviewed for injuries of unknown origin. This affected 2 residents (Resident 16 and Resident 46) of 24 residents. This had the potential to affect all of the residents. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. …
F610 citations in Nebraska
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nebraska cites F610 more often than its own record predicts
1.42 times the share F610 takes of citations nationally.
Of every deficiency written in Nebraska in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nebraska surveyors wrote
F610 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 observations, record reviews, interviews and facility policy review, the facility failed to thoroughly investigate an incident where a resident fell out of a mechanical lift requiring an ER visit and resulting in a laceration. This affected 1 of 3 (Resident 117) resident files reviewed for facility reported incidents and had the potential to affect all residents requiring an investigation. The facility census was 64. Findings are: The facility Clinical Services Manual titled, Event Management and Emergency Procedures, in effect at the time of the resident's fall was dated February 2018. …
LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on interview and record review; the facility failed to report, investigate and submit the investigation to the State Agency within the required time frame, an incident which resulted in a significant injury for Resident 4. The sample size was 1 and the facility census was 35.Findings are:Review of the facility Abuse Prevention Policy (undated) revealed allegations of abuse were to be immediately reported to the Administrator.Any employee or other interested person, who has knowledge or reason to believe that a resident has been abused was under duty to immediately report such incident or suspicion to the Administrator, the Social Service Director (SSD) and/or the Director of Nursing (DON) immediately. …
The short window
Recent years
| Year | Share of Nebraska citations | vs expected |
|---|---|---|
| 2023 | 1.55% | 1.21× |
| 2024 | 0.63% | 0.44× |
| 2025 | 2.14% | 1.42× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nebraska surveyors cite →
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