Licensure Reference Number Title 175 NAC 12.006.09(H)(iii)(1) & 12.006.09(H)(iii)(2) Based on record reviews, observations, and interviews, the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer development for 1 resident (Resident 2), of 1 resident reviewed. The facility census was 33.The facility Administrator was notified on 8/5/26 at 6:25 PM of an Immediate Jeopardy (IJ) which began on 3/29/26. The IJ was removed on 8/6/26, as confirmed by surveyor onsite verification. Findings are:A record review of a policy titled, Care Plan dated 12/1/25. …
F686 citations in Nebraska
Pressure ulcers · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nebraska cites F686 more often than its own record predicts
1.19 times the share F686 takes of citations nationally.
Of every deficiency written in Nebraska in 2025, this is the portion that was F686.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nebraska surveyors wrote
F686 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 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to implement and monitor interventions to prevent the development of pressure ulcers and to promote wound healing for 3 (Resident 1,2 and 3) of 4 residents sampled. The facility census was 150. The findings are:A.Record review of the facility's policy titled Pressure Injury Prevention Guidelines revealed it is the policy of the facility to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. …
Licensure Reference Number 175 NAC 12-006.(H)(iii)(3) Based on observation, interview, and record review; the facility failed to ensure that a pressure relief/reduction mattress was calibrated to the resident's weight to prevent the potential for worsening pressure ulcers for 1 (Resident 2) of 1 sampled resident. The facility staff identified a census of 44.Findings are:A record review of the monthly nurse meeting (a regular meeting for nursing staff and leadership to review unit performance, discuss policy updated, and address clinical or operational concerns) agenda dated 5/20/26 revealed the following: Nursing Duties: Ensure that air mattresses are plugged in and function correctly. Air mattresses are to be set to resident's weight. …
The short window
Recent years
| Year | Share of Nebraska citations | vs expected |
|---|---|---|
| 2023 | 1.55% | 0.76× |
| 2024 | 2.07% | 0.99× |
| 2025 | 2.34% | 1.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nebraska surveyors cite →
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