Prestige Care Center Of Nebraska City

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

reported an allergy to the medication. -10/3/2025 The resident refused the doxycycline and Resident 2 stated [gender] is allergic to the medication. -10/3/2025 Resident 2 called pulmonologist independently and requested medication. The facility received a faxed prescription from the pulmonologist for levofloxacin (an antibiotic medication) 750 mg take one tab daily for seven days. The orders were sent to the pharmacy.Record review of an Advanced Practice Registered Nurse (APRN) progress note dated 10/3/2025 revealed notes regarding the resident's COPD flare. The note showed the APRN assessed the resident on 9/25/2025, but Resident 2 declined treatment for a COPD exacerbation at that time and requested instead that the pulmonary specialist be notified. The pulmonary specialist was notified and subsequently adjusted Resident 2's inhaled medication regimen. Record review of HUCU (a secured messaging system for real-time communication with providers) messages revealed: -9/29/2025 at 3:16 PM facility staff notified the provider of Resident 2's request for antibiotic due to increased shortness of breath. -9/29/2025 at 3:28 PM the APRN reported [gender] saw Resident 2 on 9/25/2025 and witnessed sputum production. Resident 2 declined to be treated at that time. The APRN asked facility staff if the pulmonary specialist was notified and asked if the pulmonary specialist responded. The APRN provided orders for doxycycline 100 mg by mouth twice daily for 5 days, prednisone (a steroid medication) 40 mg by mouth daily for five days, then resume maintenance dose previously ordered, and acidophilus (a probiotic that promotes the growth of good bacteria in the digestive system) or equivalent three times daily before meals for seven days, and a chest x-ray with 2 views. -9/29/2025 at 3:30 PM facility staff reported to the APRN the resident called the pulmonologist and had breathing treatments changed. -9/29/2025 at 3:34 PM the APRN told the facility to let them know if Resident 2 was agreeable with the orders provided and directed facility staff to notify the pulmonary specialist. -9/29/2025 at 4:09 PM facility staff reported to the APRN Resident 2 reported [gender] wanted to take Levaquin and that Resident 2 reported they couldn't have doxycycline.

The facility reported allergies as penicillin and coconut. -9/29/2025 at 4:14 PM the APRN stated no allergy to doxycycline, preferred treatment for COPD flare unless pulmonology ordered otherwise. -9/30/2025 at 11:16 AM the APRN asked if the facility received a response from Resident 2's pulmonary specialist yet and further inquired if the antibiotic was started. -9/30/2025 at 11:32 AM the facility reported the resident refused the doxycycline and that there was no response from the pulmonologist. -10/2/2025 at 9:11 PM the facility said the resident refused antibiotic on the first night it was ordered (9/29/25) and provided an assessment. It has been 5 days, and Resident 2 reported she would call the pulmonologist.Record review of Resident 2's Electronic Health Record (EHR), including progress notes and scanned documents, revealed no communication with the pulmonary specialist by the facility as directed.Interview on 10/15/2025 at 11:34 AM with the Regional Director of Operations (RDO) confirmed Resident 2 called the pulmonary specialist independently, 5 days after the resident first identified to facility staff a potential allergy to doxycycline.

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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

11/18/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to complete and submit a five-day written investigation of an allegation of potential neglect for 1 (Resident 3) of 3 sampled residents. The facility staff identified a census of 41.The findings are:Record

review of a facility policy entitled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated revised 1/2025 revealed: -2F. The administrator or designee will within five working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified.Record review of Resident 3's Progress Notes revealed: -8/3/2025 Resident 3 was found by staff to be laying in the bathroom on [gender] back. The resident's upper body was in the bathroom and bilateral lower extremities extended out of the bathroom. Resident 3 did not recall how it happened. An assessment was completed by the nurse with no injuries or bruising noted. -8/4/2025 Resident 3 reported that they were getting up for the day and their feet gave out. No obvious injury was noted. Resident 3 was using a cane instead of a walker and did not have non-skid socks on. No obvious injury was noted. Resident 3 was having pain in the right wrist from the previous fall, and an X-ray was ordered. -8/5/2025 Interdisciplinary team met to review resident's fall status. Resident 3 had falls on 8/2/25, 8/3/25, and 8/4/25. The falls resulted in a fracture of the right wrist.Record review of a facility reported incident showed the facility submitted the five-day written report on 8/13/2025.An interview on 10/14/2025 at 2:50 PM with the Regional Director of Operations (RDO) confirmed the report was submitted

on day seven, two days later than required.

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

11/18/2025

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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(c)(i)Based on record review and interview, the facility failed to complete an admission 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) within the required timeframes for 1 (Resident 2) of 1 sampled resident. The facility staff identified a census of 41.The findings are:Record review of a facility policy entitled Assessment Frequency/Timeliness dated revised 9/2025 revealed: -The comprehensive admission assessment will be completed within 14 days after admission, excluding readmissions in which there is no significant change, an admission assessment was completed during the prior stay, the resident was discharged return anticipated and the resident returned within 30 calendar days as described per the MDS Manual instructions.Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.20.1 dated October 2025 revealed the MDS completion date should be no later than the 14th calendar day of the resident's admission.Record review of Resident 2's Clinical Census printed on 10/14/2025 revealed the facility admitted Resident 2 on 9/9/2025.Record review of Resident 2's admission MDS dated [DATE REDACTED] revealed MDS section Z was signed as completed on 10/11/2025.Interview on 10/15/2025 at 11:34 AM with the Regional Director of Operations (RDO) confirmed the MDS was signed as completed on 10/11/2025, 13 days late.

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

11/18/2025

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

factors identified in the skin and comprehensive assessments. Categories of interventions to consider include but are not limited to: -i. Interventions to provide a safe environment. -ii. Interventions to maintain nutrition and hydration. -iii. Interventions to protect from self-inflicted injury or injury incurred during routine care. -5. Modification of interventions a. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any skin tears, or any changes in the resident's medical condition. b. Interventions will be modified in a resident's plan of care as needed. Considerations for needed modifications include: -i. Changes in medical condition or factors affecting the risk for skin tears. -ii. New onset or recurrent skin tear. -iii. Lack of progression towards healing. -iv. Resident non-compliance. -v.

Changes in the resident's goals and preferences.

Event ID:

Facility ID:

If continuation sheet