Nebraska assisted living facility license: DHHS rules, fees and steps

Four unrelated residents: where the license starts

Nebraska’s Assisted-Living Facility Act defines an ALF as “a residential setting that provides assisted-living services for remuneration to four or more persons who reside in such residential setting and are not related to the owner.” The setting can be a home, an apartment or a facility.⁠³ DHHS puts it more simply: “anyone who provides Assisted Living services for four or more residents must be licensed as an ALF.”⁠¹

The statute counts what you provide, not what you call it. Assisted-living services means housing, three meals each day, access to staff 24 hours a day, noncomplex nursing interventions, support with activities of daily living, and resident assessment for admission and continued stay.⁠³ Activities of daily living include bathing, dressing, grooming, eating, mobility, toileting, transferring and self-administration of medication.⁠³

The statute excludes two arrangements:⁠³

• Casual care provided at irregular intervals.
• A building where residents arrange their own services. A competent resident provides for or contracts for his or her own personal or professional services, provided no more than 50 percent of the residents receive such services. Some senior apartment buildings with outside home care fall here.

Nebraska has no separate license for a small residential care home. A house with four unrelated paying residents needs the same ALF license as a 60-bed building. It pays the lowest fee tier (1 to 10 beds) and meets the same 175 NAC 4 rules.⁠¹⁠² Nebraska DHHS publishes no license or certification for homes with one to three residents.

A license is issued only for the premises and persons named in the application and cannot be transferred.⁠² If you plan a daytime program for people who go home at night, that is a separate license. See the Nebraska adult day service guide.

The nursing line an ALF cannot cross

DHHS states flatly that “an ALF is not a nursing home and cannot provide routine care by licensed nurses (RN/LPN).”⁠¹ This shapes your staffing model, your admission criteria and what you can advertise.

The statute separates two kinds of nursing tasks:⁠³

• Noncomplex interventions “can safely be performed according to exact directions,” do not change the standard procedure, and have predictable results. Your staff may perform these.
• Complex nursing interventions require nursing judgment to change standard procedures, to decide how to proceed from step to step, or to apply the nursing process across several dimensions.

The Act lets an ALF provide complex nursing interventions “on a part-time or intermittent basis.”⁠⁵ That term is defined as no more than 10 hours a week for each resident, with a predictable end within 21 days.⁠³

The rules are narrower than the statute on who delivers that care. Under 175 NAC 4-006.07C, ALF staff on duty “must not provide complex nursing interventions.” The only exception is a registered nurse assessing whether someone is suitable for admission or continued residence.⁠² You may admit or keep a resident who needs complex nursing interventions, or whose condition is not stable or predictable, only if all three conditions are met:⁠²

1. The resident (or authorized representative) and the resident’s physician or the registered nurse agree it is appropriate.
2. The resident or representative arranges the care through private duty personnel, a licensed home health agency or a licensed hospice. See the Nebraska home health agency guide.
3. The care does not compromise facility operations or endanger others.

Medication is a separate question. Every ALF must have a registered nurse who reviews medication administration policies and is responsible for training medication aides.⁠⁵ The rule lists what that training covers: storage and handling, documentation, reporting errors and adverse reactions, who directs and monitors the aides, and resident-specific training within the limits of the Medication Aide Act.⁠² On admission and every year after, residents give the facility a list of the drugs, devices, biologicals and supplements they use.⁠⁵

The administrator decides who is admitted and retained. That decision rests on the person’s care needs, the facility’s ability to meet them, and whether the person is a danger to self or others.⁠⁴

No certificate of need, but DHHS approves every building

Nebraska’s certificate-of-need program “only applies to rehabilitation and nursing home beds. No other facility, service or equipment is subject to CON.”⁠¹⁷ An ALF needs no CON, whatever its size.

Construction is the gate instead. DHHS states that “all facility construction must be approved by DHHS prior to use and occupancy.”⁠¹⁶ This applies to buildings that will be licensed once construction is finished, not only to buildings already licensed. The facility, not the architect, files the pre-construction and post-construction documents. DHHS aims to approve plans within 10 working days of receiving each set, but the time can stretch with incorrect documents or workload.⁠¹⁶ DHHS charges no fee for construction review. The State Fire Marshal charges a fee for its plan review, and only the Fire Marshal or a delegated authority approves occupancy under the Life Safety Code.⁠¹⁶ A Nebraska-licensed architect or engineer must sign the DHHS Completion Certificate.⁠¹⁶

Under the rule, DHHS may accept that architect or engineer certification instead of doing its own final physical plant inspection. The certification must attach approvals from the other code authorities, installer certifications for building systems, and schematic floor plans showing room numbers, bed locations, capacity and life safety information.⁠²

For the State Fire Code, an ALF is classified as either residential board and care or limited care, depending on which set of requirements the building meets.⁠⁶ The rules require every facility to comply with the State Fire Marshal’s fire code regulations (153 NAC 1) and the Nebraska Food Code.⁠² New construction must also meet the state building, plumbing, electrical, elevator, boiler, accessibility (156 NAC 1 to 12) and energy codes.⁠² The DHHS construction page says Nebraska has adopted the 2018 Guidelines for Design and Construction of Healthcare Facilities.⁠¹⁶ Ask DHHS Facility Construction which edition and chapters it applies to your ALF project.

Room sizes and fixtures: “existing” versus “new construction”

175 NAC 4 sets two levels of physical plant standards. An “existing facility” was licensed, or had its plans approved, before the rule took effect. “New construction” is anything built or altered on or after that date. A “new facility” is one not currently licensed, including a building switching from another license category.⁠² A house converted to an ALF is a new facility, and any remodeling counts as new construction for the remodeled part.

Scroll the table sideways to see every column.

Source: 175 NAC 4-007.03E, G, H and I.⁠² Floor area excludes closets, toilets, bathing rooms and corridors, and counts only space with ceilings at least seven feet high.⁠²

Every bedroom must sit on an outside wall with an operable window of at least six square feet per resident and an unobstructed view of at least ten feet. It must also have 45 cubic feet of enclosed storage per resident and at least three feet between beds.⁠² A bedroom may not be reached through a bathroom, kitchen, laundry or another bedroom.⁠² New facilities and new construction with a capacity of more than 16 residents need a call system or wearable call devices. Existing facilities without a call system do not have to add one.⁠²

Small homes get one kitchen concession. A location serving 16 or fewer residents may use a two-compartment sink instead of a three-compartment sink, and an automatic dishwasher with a final rinse of at least 150°F instead of 160°F.⁠²

The administrator: 21, 30 hours, and the registry

Every ALF needs an administrator responsible for day-to-day operations. That person must be at least 21 years old and on the premises enough hours to manage the facility, and must name a substitute to act during absences.⁠²

The training rule comes from statute. Administrators need 30 hours of initial training covering resident care and services, social services, financial management, administration, gerontology, and the rules governing ALFs.⁠⁷ Under 175 NAC 4, a new administrator must finish that training within the first six months in the job and then complete 12 hours of ongoing training each year.⁠² Holding an active nursing home administrator license (in Nebraska or elsewhere), or working as a hospital administrator, exempts you from both the initial and the annual training.⁠²⁠⁷

DHHS states that “anyone serving as an ALF Administrator must submit an application to be placed on the registry.”⁠¹³ The registry application asks for proof of training in one of three ways: a certificate showing dates, hours, content and trainer qualifications; college coursework covering the six topics; or completion of a DHHS-approved course. It also includes a lawful presence attestation.⁠¹⁴ DHHS’s list of approved programs open to the public, dated September 5, 2023, shows three courses of 32 to 45 hours.⁠¹⁵

The licensee must notify DHHS within five working days when the administrator position becomes vacant (naming the interim person) and again when it is filled.⁠² The DHHS page links an administrator change form for this.⁠¹

Hiring direct care staff

Nebraska sets no numeric staff-to-resident ratio for ALFs. The rule requires enough trained staff to meet the needs written into each resident’s service agreement. It also requires “at least one staff person on the premises at all times when necessary to meet the needs of the residents.”⁠² Because the statute defines assisted-living services to include access to staff 24 hours a day, plan for round-the-clock coverage.⁠³

Before and after hiring unlicensed direct care staff, 175 NAC 4-006.03A requires you to:⁠²

• Run a criminal background check through a law enforcement agency or a private company that holds criminal records. Document any decision to hire someone with a record and why the person poses no threat to residents. The Act directs DHHS to write rules requiring background checks on all direct care staff.⁠⁷
• Check four registries: the Nurse Aide Registry, the Adult Protective Services Central Registry, the Central Register of Child Protection Cases, and the Nebraska State Patrol Sex Offender Registry. A Nurse Aide Registry finding of resident abuse, neglect or misappropriation is an absolute bar. For the other three registries, you decide and document.
• Complete a health history screening before the person starts work.

Orientation must happen within two weeks of hire. It covers resident rights, the resident service agreement, infection control, emergency procedures and advance directives, residents’ special needs, abuse and neglect reporting, and disaster plans. After that, each direct care worker needs at least 12 hours of training a year.⁠²

Policies and documents DHHS expects

The Act and rules require written material that DHHS will look for at inspection:

• Pre-admission disclosure. Before admission, give applicants written information on services, staff, charges, admission and retention criteria, how the service agreement is developed, whether you offer part-time complex nursing, and whether you accept Medicaid residents and on what terms.⁠⁴
• Resident services agreement for every resident. It covers services and who provides them, rights and responsibilities, costs and payment terms, and conditions of continued residency. Update it as needs change.⁠²⁠⁴
• No third-party guarantee. You may not require a relative or anyone else to guarantee payment as a condition of admission or continued stay. A voluntary guarantor signs a separate agreement containing the statutory warnings.⁠⁴
• Grievance procedure. Each ALF must give DHHS the grievance procedure it provides to applicants, and send any revised version within seven business days after it takes effect.⁠⁸
• Menus planned to meet daily nutritional requirements, with records of food actually served kept for at least 14 days.⁠²

Filing the application, in order

1. Get plan approval

   The rule requires written DHHS approval of your schematic plan and, for new construction, of the construction plans. DHHS may instead accept an architect’s or engineer’s certification that they meet 175 NAC 4-007.⁠² File construction documents with DHHS and the State Fire Marshal and get approval before occupancy.⁠¹⁶

2. Line up the administrator

   Name the person on the application and start the registry and training process. The application asks for the administrator’s name. The training can finish up to six months after the person starts.⁠²⁠¹²

3. Complete the initial application

   The DHHS form asks for the facility and owner details, FEIN, planned occupancy date, number of beds, whether you will run an Alzheimer’s or special care unit, and profit or nonprofit status.⁠¹² Under the rule, the application also lists every person in control: owners, partners, LLC members, parent companies, board members and anyone with a financial interest, including any holder of 5 percent or more of a public company’s stock.⁠² It must also include copies of zoning approval from the relevant jurisdiction and the State Fire Marshal’s (or delegated authority’s) occupancy certificates.⁠² You must notify DHHS at least 30 days before planned occupancy so it can schedule the inspection.⁠² Individual applicants also file the Lawful Presence in the US Attestation form.⁠¹

4. Get the right signatures

   The owner signs for a sole proprietorship or partnership, two members for an LLC, and two officers for a corporation.⁠⁹

5. Pay the fee and mail the packet

   to DHHS Licensure Unit, Attn: ALF Licensing, PO Box 94669, Lincoln, NE 68509-4669. Questions go to (402) 471-3324 or [email protected].⁠¹

6. Pass the initial inspection

   DHHS conducts an announced on-site inspection within 30 working days of receiving a completed application, or later if you ask, and sends the report within 10 working days.⁠²

7. Answer any citations

   If DHHS finds violations that are not dangerous, it may ask for a statement of compliance within 10 working days. A good-faith plan leads to a regular or provisional license.⁠² A provisional license is possible when you substantially comply and nothing poses imminent danger. It lasts up to one year and cannot be renewed.⁠²⁠¹¹

175 NAC 4-003.01 describes initial licensing in two stages: you first submit evidence that you can meet the operational and physical plant standards, and the application is not complete until DHHS has every listed document. DHHS then reviews it and inspects.⁠²

Fees as published by DHHS

Source: DHHS ALF page and 175 NAC 4-004.09.⁠¹⁠² If DHHS denies your application before inspecting, it refunds the fee minus a $25 administrative fee. Once an inspection has been done, it keeps the whole fee.⁠¹ The statutory cap allows a $50 base fee plus up to $2,000 more for an ALF, so the published fees sit below the ceiling.⁠¹⁰ DHHS charges nothing for construction plan review. The State Fire Marshal’s plan review fee is separate.⁠¹⁶

Dementia care: disclosure now, endorsement on paper

If you secure or separate residents with Alzheimer’s disease or dementia, or run a special program for them, and market the facility as offering dementia care, you are an Alzheimer’s special care unit under the Alzheimer’s Special Care Disclosure Act.⁠²¹ You must then file a disclosure with DHHS and give it to anyone seeking placement. DHHS reviews it at licensure and renewal.⁠¹⁸ The disclosure covers eight areas:⁠¹⁸

• your philosophy and mission
• placement, transfer and discharge criteria
• care planning
• staff training
• physical design
• activities
• family involvement
• costs

Training must include at least four hours a year of dementia-specific training for direct care staff.⁠¹⁸ DHHS posts an Alzheimer’s Disclosure Information Form with the ALF application forms.⁠¹

A 2016 law (LB698) created a memory care endorsement on the ALF license. It requires DHHS to set qualifications covering staffing, training, dedicated programming, cultural competency, facility features and security, and to award the endorsement on application and payment of a fee.⁠¹⁹ As of 2026-10-12, the DHHS ALF page lists no endorsement application or fee, and 175 NAC 4 (effective 2007) predates the statute and has no endorsement provisions.⁠¹⁠² The official sources do not show whether DHHS has adopted endorsement rules or accepts applications. Ask the Licensure Unit at (402) 471-3324 before you advertise memory care as an endorsed service.

After licensure: April 30, inspections and changes

Every ALF license expires on April 30, whatever date it was first issued.⁠² DHHS sends a renewal notice at least 30 days before expiration. You renew with the renewal application and fee, and DHHS also offers online renewal.⁠¹ The renewal application must include State Fire Marshal occupancy certificates dated within the 18 months before the license expiration date.⁠² If you miss it, DHHS sends a final notice and holds action for 30 days. After that the license lapses, and you may not operate while it is lapsed.⁠²

After licensure, DHHS may inspect unannounced at any time. Each year it may randomly select up to 25 percent of ALFs. It may also do a focused inspection after a complaint, a death or serious injury, financial instability, a change of ownership or services, or “the passage of five years without an inspection.”⁠² Inspection results are public through the DHHS license lookup.⁠¹ If an accrediting body with standards at least as strict as Nebraska’s accredits you, you may ask within 30 days of the accreditation report to be deemed compliant. Deemed facilities are left out of the random selection.⁠²

DHHS’s change rules:⁠¹⁠²

• Sale, lease, closure or move. Give written notice 10 days before.
• New owner or new location. File a new initial application within five working days. A new owner at the same premises does not trigger a new inspection. A new location does.
• Name change. Notify DHHS within five working days.
• More beds. Give at least 30 working days’ notice before increasing licensed beds.

Some events require a report to DHHS within 24 hours:⁠²

• a resident death from suicide or violence, or after leaving the facility unnoticed
• a suspected abuse-related death
• a fire needing a fire department response
• a disaster that damages the building

Medicaid: Supported Residential Living under the AD waiver

Nebraska Medicaid pays for ALF services through the Aged and Disabled (AD) Waiver. The service, formerly called Assisted Living, is now “Supported Residential Living.” It is delivered in a licensed ALF and covers personal care, ADL and IADL help, health maintenance, medication assistance, housekeeping, laundry, essential shopping, socialization and transportation.⁠²⁰ The participant pays room and board and any Medicaid share of cost.⁠²⁰ To qualify, a participant must have Nebraska Medicaid, be 65 or older or have a disability, meet nursing facility level of care, and need waiver services.⁠²⁰ DHHS describes ALFs as “licensed through Public Health and regulated by MLTC,” its Division of Medicaid and Long-Term Care.⁠²⁰ Your pre-admission disclosure must say whether you accept Medicaid-eligible residents.⁠⁴

What may change

The ALF rule chapter is old. The state rules site lists 175 NAC 4 as effective April 3, 2007, while the general chapter of Title 175 was updated in 2025.⁠² The fee table, the six-month training deadline and the room sizes all come from the 2007 text. The official sources checked do not show a pending revision of 175 NAC 4. Ask the Licensure Unit whether one is in progress, particularly on background checks for unlicensed direct care staff and memory care endorsement, before you finalize your policies.

If your project also includes children’s programs, Nebraska licenses those separately. See the family child care home guide.

Sources

1. 1
   Nebraska Department of Health and Human Services, Licensure Unit, Assisted Living Facilities Checked 12 Oct 2026 · Back to text ↑
2. 2
   Nebraska Secretary of State, Rules and Regulations, 175 NAC 4, Assisted-Living Facilities (effective April 3, 2007) Checked 12 Oct 2026 · Back to text ↑
3. 3
   Nebraska Legislature, Neb. Rev. Stat. 71-5903 (Assisted-Living Facility Act, definitions) Checked 12 Oct 2026 · Back to text ↑
4. 4
   Nebraska Legislature, Neb. Rev. Stat. 71-5905 (Admission, retention, resident services agreement) Checked 12 Oct 2026 · Back to text ↑
5. 5
   Nebraska Legislature, Neb. Rev. Stat. 71-5906 (Complex nursing interventions) Checked 12 Oct 2026 · Back to text ↑
6. 6
   Nebraska Legislature, Neb. Rev. Stat. 71-5907 (State Fire Code classification) Checked 12 Oct 2026 · Back to text ↑
7. 7
   Nebraska Legislature, Neb. Rev. Stat. 71-5908 (Rules and regulations; administrator training) Checked 12 Oct 2026 · Back to text ↑
8. 8
   Nebraska Legislature, Neb. Rev. Stat. 71-5909 (Grievance procedure) Checked 12 Oct 2026 · Back to text ↑
9. 9
   Nebraska Legislature, Neb. Rev. Stat. 71-433 (License application) Checked 12 Oct 2026 · Back to text ↑
10. 10
    Nebraska Legislature, Neb. Rev. Stat. 71-434 (License fees) Checked 12 Oct 2026 · Back to text ↑
11. 11
    Nebraska Legislature, Neb. Rev. Stat. 71-437 (Provisional license) Checked 12 Oct 2026 · Back to text ↑
12. 12
    Nebraska Department of Health and Human Services, Licensure Unit, Assisted-Living Facility Licensure Initial Application Checked 12 Oct 2026 · Back to text ↑
13. 13
    Nebraska Department of Health and Human Services, Licensure Unit, Assisted Living Facilities Initial Administrator Training Checked 12 Oct 2026 · Back to text ↑
14. 14
    Nebraska Department of Health and Human Services, Licensure Unit, Application for Approval of Initial Assisted-Living Facility Administrator Training Checked 12 Oct 2026 · Back to text ↑
15. 15
    Nebraska Department of Health and Human Services, Licensure Unit, Department Approved Assisted-Living Facility Administrator Programs (September 5, 2023) Checked 12 Oct 2026 · Back to text ↑
16. 16
    Nebraska Department of Health and Human Services, Licensure Unit, Facility Construction Checked 12 Oct 2026 · Back to text ↑
17. 17
    Nebraska Department of Health and Human Services, Licensure Unit, Facilities, Services and Establishments Checked 12 Oct 2026 · Back to text ↑
18. 18
    Nebraska Legislature, Neb. Rev. Stat. 71-516.04 (Alzheimer's special care unit disclosures) Checked 12 Oct 2026 · Back to text ↑
19. 19
    Nebraska Legislature, Neb. Rev. Stat. 71-472 (Memory care endorsement) Checked 12 Oct 2026 · Back to text ↑
20. 20
    Nebraska Department of Health and Human Services, Services on the Aged and Disabled Waiver Checked 12 Oct 2026 · Back to text ↑
21. 21
    Nebraska Legislature, Neb. Rev. Stat. 71-516.03 (Alzheimer's Special Care Disclosure Act, definitions) Checked 12 Oct 2026 · Back to text ↑

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