LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPIP) failed to identify ongoing issues relevant to F550, F580, F609, F657, F676, F689, F712, F730, F755, F758, F761, F812, F835 and F867 and implement plans of action to identify and correct the deficient practice. The QAPI failed to ensure repeated deficiencies at F692 and F697 were corrected and the correction maintained. This deficient practice had the potential to affect all residents who reside in the facility. The facility staff identified a census of 92. Findings are: Record review of a undated facility Quality Assurance and Performance Improvement (QAPI) program revealed the following information: -Goal: -1. …
F865 citations in Nebraska
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nebraska cites F865 less often than its own record predicts
0.82 times the national share — cited less often here than elsewhere.
Of every deficiency written in Nebraska in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nebraska surveyors wrote
F865 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 12-006.07(C) Based on record review and interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI - a facility process that identifies problems in the facility and works to correct the concerns) identified and addressed concerns related to deficient practice identified on the annual survey 2026 ( F550, F605, F641, F677, F684, F686, F688, F692, F695, F712, F756, F761, F835, F838, F843, F880, and F865 ) This had the potential to affect 74 residents who resided in the facility. …
Licensure Reference Number 175 NAC 12-006.02(I)Based on record review and interview; the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) plan was effective in addressing recently identified deficient practice and preventing repeat deficient practice with similar concerns. This had the potential to affect all facility residents. The facility census was 45. Findings are: Review of the facility policy Quality Assurance and Performance Improvement Plan (QAPI)/ and Assurance (QAA) dated 5/23/23 revealed the facility developed a process for conducting quality activity and identification and correction of deficiencies as well as opportunities for improvement through continuous attention to quality of care, quality of life, and resident safety. …
The short window
Recent years
| Year | Share of Nebraska citations | vs expected |
|---|---|---|
| 2023 | 0.56% | 3.27× |
| 2024 | 0.18% | 0.97× |
| 2025 | 0.19% | 0.82× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nebraska surveyors cite →
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