The facility failed to provide hospitals with critical details about the residents' medications, diagnoses, care plans, and recent vital signs when they were transferred after falls in late August, according to a federal inspection completed in September.
One resident fell on August 26 and was sent to the hospital for evaluation and treatment. The second resident fell the next day, August 27, and was also transferred for medical care.
In both cases, inspectors found no evidence that Prestige Care sent the federally mandated transfer documentation to the receiving hospitals. The facility's administrator confirmed during a September 22 interview that the required information should have been sent but wasn't.
Federal regulations require nursing homes to provide extensive medical information when transferring residents to hospitals. The missing documentation includes contact information for the resident's doctor, advance directive details, current medications and when they were last given, recent lab results and diagnostic tests, and special care instructions.
The transfer requirements also mandate that facilities share details about treatments and medical devices the resident uses, such as oxygen, implants, IVs, or catheters. Nursing homes must communicate special risks including fall risk, bleeding risk, and aspiration precautions.
Prestige Care's own policy, revised in February 2025, outlines these exact requirements. The policy states that for any transfer to another healthcare provider, the facility must provide the receiving institution with the resident's baseline and current mental, behavioral and functional status, along with the reason for transfer and recent vital signs.
The policy also requires staff to share all diagnoses and allergies, medication information including timing of last doses, and the most recent relevant lab work and diagnostic tests. Special instructions for ongoing care must be communicated, including any transmission-based precautions for infectious diseases.
Without this information, hospital staff treating the transferred residents would lack crucial context about their medical conditions, medications, and care needs. The missing documentation could delay treatment or lead to medication errors or other complications.
The facility admitted the first resident on March 15, 2023, meaning they had been living at Prestige Care for more than two years before the August fall. The second resident was admitted on March 6, 2024, and had been at the facility for about five months when they fell.
Prestige Care operates with a census of 43 residents, according to facility staff who spoke with inspectors. The inspection was conducted in response to a complaint about the facility's practices.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the failure to provide required transfer documentation represents a breakdown in a basic safety protocol designed to ensure continuity of care.
The inspection report shows that facility staff were aware of their obligations under the transfer policy but failed to follow through when actual emergencies occurred. The administrator's acknowledgment that the documentation should have been sent indicates the facility understood the requirements but didn't implement them.
The August falls occurred within 24 hours of each other, suggesting either a coincidental cluster of incidents or potential environmental hazards that led to multiple residents falling in quick succession. Both residents required hospital-level evaluation and treatment for their injuries.
Nursing home transfers to hospitals are common, particularly after falls, which represent one of the most frequent medical emergencies in long-term care facilities. The required documentation serves as a critical communication tool between the nursing home and hospital staff, ensuring that residents receive appropriate care without dangerous gaps in medical information.
The inspection findings reveal a disconnect between Prestige Care's written policies and actual practice. While the facility had updated its transfer policy as recently as February 2025, staff failed to implement the requirements when real situations arose just months later.
Federal regulators require nursing homes to have systems in place to ensure seamless communication during resident transfers. The failure to provide required documentation suggests broader problems with emergency response protocols and staff training on regulatory compliance.
The two residents who fell and were transferred without proper documentation experienced a gap in the continuity of their care at a vulnerable moment when they needed medical attention for their injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Care Center of Nebraska City from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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