Prestige Care Center of Nebraska City

Inspectors wroteLicense Reference Number 175 NAC 12-006.09(I) Based on record reviews, interviews and observations, the facility staff failed to: evaluate risks and hazards, identify causative factors, thoroughly investigate, implement interventions to reduce risks and hazards, implement new interventions to help reduce risks, monitor effectiveness and/or modify interventions all related to falls for 4 (Resident 3, 4, 5, and 6) of 5 sampled residents. The facility staff identified a census of 46. A record review of the facility's Fall Prevention Program with a revision date of 01/2026 revealed the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observations, interviews and record reviews, the facility staff failed to complete hand hygiene between glove changes for 2 (Residents 5 and 6) of 3 resident sample, complete glove changes when moving from a contaminated surface to a clean surface for 1 (Resident 5) of 1 sample resident, failed to put on personal protective equipment when administering tube feeding for 1 (Resident 7) of 1 sample resident, failed to secure a gown when providing catheter cares for 1 (Resident 5) of 1 sample resident and failed to have EBP signs on the doors for 1 (Resident 5) of 2 sample resident. The facility staff identified a census of 46. Record Review of the facility's policy Enhanced Barrier Precautions with a revision date of 1/2026 revealed the following: Policy: [...]

Inspectors wroteLicense Reference Number 175 NAC 12-006.09(H) The facility failed to ensure a provider was contacted to provide pain management for Resident 4. The facility has a census of 46. A record review of the facility's Pain Management policy dated 04/2019 and reviewed 02/2025 revealed the following:Policy:The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Recognition:In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will:Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. [...]

Inspectors wroteBased on interview and record review the facility staff failed to include the resident profile in the facility assessment and failed to update the facility assessment annually. The facility staff identified a census of 46.

Inspectors wroteBased on interviews and record reviews the facility staff failed to have patient transportation agreements with outside agencies and dialysis centers. The facility staff identified a census of 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on record review, observations and interviews, the facility failed to implement interventions to protect from potential elopement for 4 (Residents 1, 2, 4, and 5) of 5 sampled residents. The facility staff identified a census of 49.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19 Based on observations and interviews, the facility failed to ensure the Alzheimer's Care unit was free of odor. This had the potential to affect 12 residents living in the Alzheimer's Care unit and failed to ensure 1 (room [ROOM NUMBER]) of 11 rooms in the Alzheimer's Care unit was clean. The facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) The facility failed to notify the power of attorney of new orders and change of plan in care for 1 (Resident 36) of 1 sampled resident. The facility staff identified a census of 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)Based on record review and interview, the facility failed to document signs and symptoms of pain for the continued use of as-needed opioid pain medication for 1 (Resident 45) of 6 sampled residents. Facility staff identified a census of 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04(D) Based on observation, interview, and record review the facility failed to ensure exhaust vents worked in 2 (room [ROOM NUMBER] and 325) of 16 sample rooms. The facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18DBased on observation, interview and record review the facility failed to ensure that staff performed hand hygiene and gloving in a manner to prevent cross contamination when providing cares to 3 of 3 residents surveyed (Residents 1, 2 and 3). The facility had a census of 42.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(J)(iii)Based on observation, interview and record review, the facility failed to prevent dehydration (a condition where the body loses more fluid than it takes it, preventing it from functioning properly) for 1 resident (Resident1) of 3 residents surveyed. The facility had a census of 42.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview, the facility failed to notify the pulmonary specialist of medication changes as directed by the primary care provider for 1 (Resident 2) of 3 sampled resident. The facility staff identified a census of 41.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(3)Based on record review and interview, the facility failed to implement interventions to prevent falls for 1 (Resident 3) of 3 sampled residents; and the facility failed to investigate causal factors and implement interventions to prevent skin tears for 1 (Resident 2) of 1 sampled resident. The facility staff identified a census of 41.

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on observation, interview, and record review, the facility failed to implement interventions to prevent potential falls for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 43.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review, the facility failed to maintain the cleanliness and condition of walls, floors, fixtures, doors, carpets, bathroom ceiling ventilation covers in 17 (rooms 104, 106, 108, 110, 111, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 319 and 324) of 28 occupied resident rooms in the facility. The facility census was 40.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i)(1 Based on record review and interviews, the facility failed to initiate interventions to prevent further weight loss for 1 (Resident 193) of 1 sampled resident. The facility identified a census of 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on observation, record review and interview, the facility failed to provide a trauma-based assessment for 2 (Resident 24 and 34) of 2 sampled residents who were diagnosed with Post Traumatic Stress Disorder. The facility had a census of 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i) Based on interview and record review, the facility staff failed to ensure practitioner's orders were implemented related to ordered medications, ordered laboratory (Labs) testing and obtaining weights for Residents 1 and failed to obtain weights as ordered for Resident 3 of 3 sampled residents. The facility census was 46 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interview, the facility staff failed to notify the practitioner of a change in condition and to update the practitioner as ordered for 1 [Resident 3] of 3 sampled residents. Facility had a total census of 46 residents.

Inspectors wroteLicensure Reference Number NAC 12-006.04C2 Based on record review and interview, the facility failed to ensure a Registered Nurse was present in the facility for a continuous period of 8 hours a day, 7 days a week. This had the potential to affect all residents who reside in the facility. The facility had a census of 48.

Inspectors wroteLicensure Reference Number 12-006-11 E Based on observations, interviews and record reviews; the facility failed to utilize proper hand hygiene practices during the preparation and serving of food to prevent foodborne illness. This had the potential to affect all residents in the facility who eat food from the kitchen. The facility census was 48.

Inspectors wroteLicensure Reference Number 12-006-18 B Based on observation, interview and record review; the facility failed to maintain the cleanliness and condition of ventilation systems, fixtures and floors in 7 resident bathrooms (rooms 316, 317, 318, 320, 321, 322 and 325) of 10 occupied resident rooms on the secured unit of the facility. The facility census was 48.

Inspectors wroteLicensure Reference Number 12-006.09 D7a Based on observation, record review and interview, the facility failed to ensure that chemicals were secured and not accessible to 2 (Residents 23 and 43) residents that were independent with ambulation, exhibited wandering behaviors [movement with no purpose or safety awareness], had poor safety awareness, and resided on the secured unit of the facility. The facility had 10 residents that resided on the secured unit of the facility. The facility census was 48.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to implement interventions, evaluate casual factors and evaluate the condition of the development of a pressure ulcer for 1 (Resident 40) of 4 sampled residents. The facility staff identified a census of 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to implement a pain management program for 1 sampled resident (Resident 40). The facility had a total census of 36 residents. The sample size was 12.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to clarify and implement a medication for the treatment of COVID-19 for 1 (Resident 26) of 4 residents reviewed. The facility had a total census of 36 residents.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.18Ea1 LICENSURE REFERENCE NUMBER 175 NAC 12-00618Ea2 Based on observations, record reviews and interview; the facility staff failed to ensure bathing water temperatures were maintained at a level to prevent the potential of scalding. This had the potential to affect all residents in the facility. The facility failed to ensure hand sink water temperatures were maintained to prevent the potential for scalding for 1 (Resident 36) of 16 residents on the initial pool and failed to ensure a clutter free environment to prevent falls for 1(Resident 13) of 2 sampled residents.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record reviews and interview; the facility management failed to utilize its resources to attain or maintain the highest practicable physical, and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17A(2) Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review, the facility failed to ensure staff and visitors' COVID-19 screening questions were completed and evaluated prior to entrance into the facility and failed to ensure oxygen tubing was changed and stored to prevent the potential for contamination for Resident 39 and 2. This had the potential to affect all residents in the facility. Total census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to prevent the spread of COVID-19 as evidenced by the following: -1). Failure to complete contact tracing and perform outbreak testing accordingly. -2). Failure to perform COVID-19 testing in accordance with manufacturer's directions. These failures had the potential to affect all residents residing in the facility. At the time of the survey, a total of 4 residents and 1 staff member had tested positive for COVID-19 since the start of the outbreak. The facility had a total census of 36 residents.

Inspectors wroteBased on observations, interviews, and record review; the facility failed to fully implement the facility COVID-19 Contingency Plan for staff with exemptions. Less than 25% of staff were unvaccinated. Total census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(17) Based on observation, interview, and record review, the facility failed to address Resident Council grievances (complaint or protest) regarding housekeeping, maintenance, food, activities, and staff concerns. This had the potential to affect 32 residents on the 100 and 200 hallways. Total census was 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review; the facility failed to ensure the negative ventilation system was working and maintain residents room lighting, floors, walls, light fixtures, doors, outdoor fencing clean and in good repair. This had the potential to affect all 38 residents in the facility. Total census was 38.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05 Based on record review and interview; the facility staff failed to provide written notice of the reason for transfer and failed to notify the Ombudsman of the residents who discharged from the facility for 3 (Resident 2, 20 and 40) of 5 residents. The facility staff identified a census of 38.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observations, record review and interview; the facility staff failed to evaluate and implement interventions to promote healing for skin breakdown for 1 (Resident 22) of 1 sample resident. The facility staff identified a census of 38.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observations, record review and interview; the facility staff failed to ensure water was within reach or available for 3 (Resident 22, 25 and 36) of 3 sampled residents, failed to implement assessed interventions to prevent further weight loss for 1 (Resident 20) and failed to obtain weekly weights for 1(Resident 2) of 5 sampled residents. The facility staff identified a census of 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to implement non pharmacological interventions prior to the administration of antianxiety medications for Resident 242, failed to address the use of an antianxiety as needed medication in excess of 14 days per regulation for Resident 26 and failed to complete a sleep study for Resident 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11D Based on observation and interview, the facility staff failed to ensure that food was being served at temperatures to prevent foodborne illness. The facility had a census of 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-007.03I5 Based on observation and interview, the facility failed to ensure each resident in a semiprivate (a room shared by 2 people) room had individualized closet space. This had the potential to affect 32 of 38 residents in the facility. Total census was 38.

Inspectors wroteBased on record review and interview, the facility staff failed to issue the Advanced Beneficiary Notice (ABN) to 1 (Resident 39) of 3 sampled residents which did not give the resident/resident representative the opportunity to appeal the facility's decision to discontinue Medicare A benefits. The facility had a census of 39.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to submit a investigation of an injury of unknown source to the required state agency within 5 working days for 1 (Resident 36) of 7 investigations reviewed. The facility staff identified a census of 38.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6(7) Based on observation, interview, and record review, the facility failed to obtain an oxygen order for Resident 23. This affected 1 of 3 sampled residents. Total census was 38.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to evaluate and obtain treatment for Depression (a mental health disorder the presents as persistent depressed mood or loss of interest in activities, causing significant impairment to daily life) for Resident 191. This affected 1 of 2 sampled residents. Total census was 38.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 25 medications administered revealed 4 errors resulting in an error rate of 16%. The errors effected 1 (Resident 10) of 3 residents sampled. The facility staff identified a census of 38