Licensure Reference Number 175 NAC 12-006.07 Based on observations, record reviews and interviews, the facility Quality Assurance Performance Improvement (QAPI) team failed to identify high water temperatures to avoid the potential for burns and failed to maintain compliance as evidenced by repeat deficient practice. The facility census was 107. Findings are: Review of the facility Quality Assessment and Assurance (QA&A) policy dated March 2023 revealed the following members: Administrator, Director of Nursing, Assistant Director of Nursing, Business office manager (BOM) and Assistant BOM, housekeeping supervisor, Social services director, Maintenance Director, Dietary manager, Activities director, Medical records, Staffing, Concierge. …
F867 citations in Nebraska
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nebraska cites F867 less often than its own record predicts
0.89 times the national share — cited less often here than elsewhere.
Of every deficiency written in Nebraska in 2025, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nebraska surveyors wrote
F867 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 observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance (QAPI, . It is a data-driven, proactive program required by the Centers for Medicare and Medicaid Services for healthcare facilities like nursing homes to continuously track and elevate patient care safety and quality) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. This had the potential to affect all residents that resided in the facility. The facility census was 79. …
Licensure reference Number 175 NAC 12-006.07(C)Based on observation, interview, and record review, the facility failed to ensure the QAPI program identified and addressed concerns related to deficient practice for elopement and falls prior to a complaint survey. This had the potential to affect all residents in the facility. The facility identified a census of 65.Findings are:A.Record review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership with a revision date of 1/2024 revealed the following:Policy: the Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and the governing body.Policy Interpretation and… …
The short window
Recent years
| Year | Share of Nebraska citations | vs expected |
|---|---|---|
| 2024 | 0.27% | 0.60× |
| 2025 | 0.29% | 0.89× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nebraska surveyors cite →
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