The reporting requirement is not complicated.
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Without a qualified person in that seat, all of it is improvised.
Inspectors classified the lapse as isolated, with no actual harm documented, but noted the potential for more than minimal harm to residents.
That finding sits at the center of a complaint inspection completed August 27, 2025, at the Kimball County Manor nursing facility in Kimball, Nebraska.
The director acknowledged the gap between what staff were doing and what the assessment required.
The citation, issued under a regulatory tag that covers unnecessary medication use, was filed following a complaint inspection completed on August 28, 2025.
Nobody qualified was in charge.
Federal inspectors rated the violation as causing actual harm.
That is what federal inspectors documented when they arrived at the nursing home at 6757 Mayfield Rd on August 27, 2025, following a complaint.
The observation happened at 2:55 p.m.
The citation fell under a category regulators call Quality of Life and Care Deficiencies.
In the language of federal inspections, that phrase, "potential for more than minimal harm," is not a technicality.