Licensure Reference Number 175 NAC 12-006.04Based on observation, record review, and interview the facility failed to have sufficient staff to complete resident assessments and resident observations as required to identify and monitor residents at risk for skin injury. This had the potential to affect all facility residents. The facility census was 33. The facility Administrator was notified on 8/5/26 at 6:25PM 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:Record review of the policy titled, Skin Assessment Pressure Ulcer Prevention and Documentation Requirements dated 3/30/26 revealed that all residents will be identified for their risk of developing pressure ulcers on admission/readmission by… …
F725 citations in Nebraska
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nebraska cites F725 more often than its own record predicts
1.00 times the share F725 takes of citations nationally.
Of every deficiency written in Nebraska in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nebraska surveyors wrote
F725 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 12-006.04C Based on observation, interview, and record review, the facility failed to ensure sufficient staff to care for residents in the Cottonwood Unit of the facility. This failure resulted in a resident waiting over 2 hours for pain medication, residents not being assisted with meals or ADLs (Activities of Daily Living), residents with pressure ulcers not being assessed or provided treatments as ordered by their physicians, and residents waiting extended periods of time for call lights to be answered. This affected 32 of the 46 residents that resided in the facility. The findings are: A. …
Licensure Reference Number 175 NAC 12-006.04 Based on observations, interviews, and record review; the facility failed to have sufficient staff to ensure residents' call lights were being answered in a timely manner and to ensure resident meal trays were served in their rooms during the posted meal times. This had the potential to affect all residents. The facility identified a census of 90. Findings Are:An interview on 8/31/2026 at 3:04 PM with the Unit Manager confirmed allowing a resident's call light to go unanswered for more than 10 minutes was too long. A.An observation on 8/25/2026 at 8:11 AM revealed the call light had been activated in resident room [ROOM NUMBER]. …
The short window
Recent years
| Year | Share of Nebraska citations | vs expected |
|---|---|---|
| 2023 | 0.42% | 0.53× |
| 2024 | 0.72% | 0.90× |
| 2025 | 0.78% | 1.00× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nebraska surveyors cite →
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