Based on interview and record review the facility staff failed to include the resident profile in the facility assessment and failed to update the facility assessment annually. The facility staff identified a census of 46. Findings are:A record review on 7/16/2026 11:04 AM of the facility assessment revealed the following:-Overview of the Assessment Tool: This is an optional template provided for nursing facilities, and if used, it may be modified. Each facility has flexibility to decide the best way to comply with this requirement.-The tool is organized into three parts: resident profile section that includes the numbers, disease/conditions, physical and cognitive disabilities, acuity, and ethnic/culture/religious factors that impact care. …
F838 citations in Nebraska
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nebraska cites F838 less often than its own record predicts
0.39 times the national share — cited less often here than elsewhere.
Of every deficiency written in Nebraska in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nebraska surveyors wrote
F838 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.
Based on interviews and record review, the facility failed to review and update the Facility Assessment annually. The current facility census was 41 residents. Findings are: A review of the most recent facility assessment, updated on 11/2018 and reviewed on 01/2019, failed to document the current Administrator, Chief Nursing Officer and most of the administrative staff. The average daily census was documented as 15. On 08/12/20 at 11:03 AM, an interview was conducted with the Administrator, who stated the Facility Assessment should have been updated on 01/2020, the same month (gender) started at the facility, but (gender) had other things to look at first. …
The short window
Recent years
| Year | Share of Nebraska citations | vs expected |
|---|---|---|
| 2023 | 0.14% | 0.84× |
| 2025 | 0.10% | 0.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nebraska surveyors cite →
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