Prestige Care Center Of Nebraska City

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Licensure Reference Number 175 NAC 12-006.02(H)Based on interview and record review, the facility failed to complete a thorough investigation for an allegation of abuse for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Abuse, Neglect and Exploitation dated revised 01/2025 revealed: -A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -B. Written procedures for investigations include: -1. Identifying staff responsible for the investigation; -2. Exercising caution in handling evidence that could be used in a criminal investigation. -3. Investigating different types of alleged violations; -4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; -5.

Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred,

the extent, and cause; and -6. Providing complete and thorough documentation of the investigation.Record

review of Resident 1's admission Record printed 9/22/2025 showed the facility admitted the resident on 3/15/2023.Record review of Resident 1's Medical Diagnosis printed 9/22/2025 revealed the resident had diagnoses of chronic obstructive pulmonary disease (pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), schizophrenia (a mental illness that is characterized by disturbances in thought, perception, and behavior, by a loss of emotional responsiveness and extreme apathy, and by noticeable deterioration in the level of functioning in everyday life), and age-related osteoporosis.Record review of Resident 1's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 7/10/2025 revealed the resident had a Brief

Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15. According to the MDS manual, a score of 13 indicated the resident was cognitively intact. Further

review of the MDS revealed Resident 1 displayed verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others on one to three days during the review period.Record review of a facility reported investigation dated 12/5/2024 showed on 12/1/2024 Resident 1 reported pain under the right breast to the licensed nurse. The licensed nurse assessed the area which revealed no redness or change in skin condition. Resident 1 reported that someone hit [gender] there and that is why it hurt. Further review of the investigation showed that the report lacked staff and resident interviews.Interview on 9/22/2025 at 3:15 PM with the facility Administrator (ADM) confirmed that staff and resident interviews were not documented. The ADM further confirmed the investigation was not complete.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prestige Care Center of Nebraska City

1420 North 10th Street Nebraska City, NE 68410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Based on record review and interview, the facility failed to provide federally required transfer documentation to the receiving health care institution for 2 (Resident 1 & 2) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Transfer and Discharge (including AMA) dated revised 2/2025 revealed: -8. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: -a. Contact information of the practitioner who was responsible for the care of the resident; -b. Resident representative information, including contact information; -c. Advance directive information; -d. All other information necessary to meet the resident's needs, which includes but may not be limited to: -i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; -ii. Diagnoses and allergies; -iii.

Medications (including when last received); and -iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. -e. All special instructions and/or precautions for ongoing care, as appropriate such as: -i. Treatments and devices (oxygen, implants, IVs, tubes/catheters); -ii. Transmission-based precautions such as contact, droplet, or airborne; -iii. Special risks such as risk for falls, elopement, bleeding, pressure injury and/or aspiration precautions; -f. The resident's comprehensive care plan goals; -h. Additional information, if any, outlined in the transfer agreement with the acute care provider.A. Record review of Resident 1's admission Record revealed the facility admitted the resident on 3/15/2023.Record review of Resident 1's Progress Notes (PN) dated 8/26/2025 revealed Resident 1 sustained a fall and was transferred to the hospital for evaluation and treatment.Record review of Resident 1's Electronic Health

Record (EHR) including progress notes, assessments, and scanned documents lacked evidence the facility sent federally required information to the hospital at the time of transfer.Interview on 9/22/2025 at 3:15 PM with the facility Administrator (ADM) confirmed there was no evidence that federally required transfer documentation was sent to the hospital and the facility should have.B. Record review of Resident 2's admission Record revealed the facility admitted the resident on 3/6/2024.Record review of Resident 2's PN dated 8/27/2025 revealed the resident had sustained a fall and was transferred to the hospital for evaluation and treatment.Record review of Resident 2's EHR including progress notes, assessments, and scanned documents lacked evidence the facility sent federally required information to the hospital at the time of transfer.Interview on 9/22/2025 at 3:15 PM with the ADM confirmed there was no evidence that federally required transfer documentation was sent to the hospital and the facility should have.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prestige Care Center of Nebraska City

1420 North 10th Street Nebraska City, NE 68410

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -12/19/2024 fall mat next to bed -1/22/2025 ensure resident is wearing non-skid socks and or footwear. -2/13/2025 resident to have flannel sheets on bed at all times.

Bolster mattress placed by hospice. -5/19/2025 dycem (a brand of non-slip, reusable, and antimicrobial material available in mats, rolls, and netting, designed to provide stability and control contamination in both daily living and professional environments) placed in tilt w/c. -7/21/2025 assist to toilet after meals -7/29/2025 Non-skid strips in front of toilet and sink in bathroom -8/12/2025 Scheduled toileting before and

after meals and at HS (bed time) -8/13/2025 15-minute checks x 14 days.Record review of 15-minute checks dated 8/27/2025 through 9/22/2025 revealed: -No 15-minute check sheet was located for 9/4/2025. -12:15 am through 5:45 pm checks were left blank for 9/5/2025. -No 15-minute check sheet was located for 9/7/2025. -12:15 am through 5:45 am checks were left blank for 9/12/2025. -All other dates had 15-minute checks completed in full.Observation on 9/22/2025 at 8:23 AM revealed Resident 2 was asleep in bed with

the bed in low position and the call light within reach. A bolster mattress (a mattress with an integrated perimeter of soft foam designed to create a safe, defined edge around the mattress to prevent falls and entrapment without the use of restrictive side rails) was in place. There was no fall mat at the bedside.Observation on 9/22/2025 at 11:55 AM, Nurse Aide (NA)-A assisted Resident 2 to the bathroom

after the noon meal. Resident 2 was wearing non-skid socks. Non-skid strips were noted in front of the toilet and sink in Resident 2's bathroom. An interview on 9/22/2025 at 11:58 AM with NA-A confirmed there was no fall mat at the resident's bedside. NA-A further confirmed there was no dycem in the seat of the wheelchair and there was no sign displayed in the room for the resident to call for assistance.An interview

on 9/22/2025 at 3:15 PM with the facility Administrator confirmed interventions listed on the care plan are expected to be implemented.

Event ID:

Facility ID:

If continuation sheet