Prestige Care Center of Plattsmouth
602 South 18th Street, Plattsmouth, NE 68048 · For profit - Limited Liability company · 111 certified beds · (402) 296-2800 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.4% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.1% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.6% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.3% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.3% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.4% | 18.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.1% | 19.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 90.9% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.3% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.0% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 33.6% | 20.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 7.0% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.4% | 75.9% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 15.2% | 20.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.9% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.32 | 1.81 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.27 | 1.92 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.0%CMS range 28.0–57.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.0–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.2–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 111 beds and averages 84.4 residents a day — about 76% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.23 hrs/resident/day on weekends vs 3.34 on weekdays — 3% thinner on weekends. RN hours go from 0.38 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · Fcited before2026-04-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Nebraska Licensure reference: NAC 75: 12-006.11(E); NAC 75: 12-007.10(A) Based on observation, interview, and record review, the facility failed to ensure all foods were labeled, sealed, and dated after opening, ensure outdated foods were not available for use, and satellite refrigerators were kept clean, ensure staff performed hand hygiene and gloving to prevent cross contamination during meal prep and dining, and failed to handle resident dinnerware and utensils in a sanitary manner. The facility census was 87 residents.Findings are: Record review of the facility Food Safety Requirement policy revised 03/2026 revealed the following: -Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. -Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. -Preparation of food, including thawing, cooking, cooling, holding, and reheating. - Employee hygienic practices.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-02 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.19(C)(i)Licensure Reference Number 175 NAC 12.006.18(B)Licensure Reference Number 175 NAC 12.006.18(D)Based on observation, interview, and record review, the facility failed to ensure staff handled clean clothing and linens, completed hand hygiene during 1 (Resident 2) of 4 sampled resident's wound care, failed to ensure a medication aide wore gloves when opening a medication capsule for 1 (Resident 69) of 4 sampled residents, failed to ensure 1 (Resident 34) of 1 sampled resident's Continuous Positive Airway Pressure device (CPAP)(a machine used to treat sleep apnea) mask and nebulizer (neb)(a machine used to deliver liquid medications to the lungs) kit were stored, failed to ensure staff performed hand hygiene between glove changes to prevent potential cross contamination (transfer of bacteria from one surface to another), and failed to follow Enhanced Barrier Precautions (EBP) during high contact cares for Resident 66. The facility census was 87. Findings are:A. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-04-02 · tag F0923 — widespreadHave enough outside ventilation via a window or mechanical ventilation, or both.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.007.04(D)Licensure Reference Number 175 NAC 12.006.19(A)Licensure Reference Number 175 NAC 1.009.02Based on observation, interview, and record review, the facility failed to ensure the exhaust ventilation system was working in all resident's restrooms. This affected all residents that resided in the facility. The facility census was 87. Findings are:A record review of the facility's Safe and Homelike Environment policy with a date reviewed/revised of 03/2026 revealed the resident rooms would have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Observation on the following dates and times revealed the following resident restroom exhaust ventilations systems (vents) were not working and pulling air from the restrooms: - 03/30/2026 at 9:01 AM in room [ROOM NUMBER] - 03/30/2026 at 1:47 PM in room [ROOM NUMBER] - 03/30/2026 at 9:51 AM in rooms [ROOM NUMBERS] - 03/30/2026 at 10:23 AM in room [ROOM NUMBER] - Strong urine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Nebraska Licensure reference: 175 NAC 12-006.09(I)Nebraska Licensure reference: 175 NAC 1-009.04(D)(i)(1&2)Based on observation, interview, and record review, the facility failed to maintain safe hot water temperatures to prevent accidents in occupied resident rooms 301, 302, 303, 306, 308, 503, 506, and 512. The facility census was 87 residents.The findings are: Review of facility's Safe Water Temperature policy, implemented 4/19 and revised 5/25 indicated that the maximum water temp for sinks is 120 degrees. A. Record review of admission Record for Resident 30 revealed admission date of 2/7/23 with diagnoses that included severe vascular dementia with mood disturbance. Resident 30's Annual Minimum Data Set (MDS, a standardized assessment tool completed by long-term care facilities to evaluate resident health status and care needs) was completed in February of 2026. The Brief Interview for Mental Status (BIMS) score obtained on the MDS was 0. A BIMS score of 0 indicated severe cognitive impairment. Further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-02 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation and interview, the facility staff failed to ensure food was provided in a manner that was maintained at a temperature that was appealing to residents. This had the potential to affect 72 residents. Findings are:Observation on 04/01/2026 at 1:55 PM revealed the final room trays were being plated to serve to the facility residents by the Dietary Manager (DM). The lunch meal consisted of pork, mashed potatoes, brown gravy, spinach bake, and green beans. During the observation a test tray was requested to be prepared and provided with room trays for residents who ate in their rooms. On 04/01/2026 at 2:09 PM the DM accompanied the room trays including the test tray out of the kitchen. Once the final resident room tray was delivered, the test tray was delivered to the recreation room at 2:13 PM. The DM and using the facility thermometer obtained the temperature of the food with the following results:-The pork temperature did not register. The pork had good flavor but was cold.-The mashed potatoes and gravy temperature did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-02 · tag F0917 — patternMake sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents in semi-private rooms had their own private designated closet space. The facility census was 87. Findings are:A record review of the facility's Resident Rooms policy with a date reviewed/revised of 03/2026 revealed that each resident bedroom would have individual private closet space with cloths racks and shelves assessable to the resident. A record review of the facility's Safe and Homelike Environment policy with a date reviewed/revised of 03/2026 revealed the facility will provide sufficient individual closet space in each resident room. A record review of the facility's Daily Census dated 04/01/2026 revealed 11 rooms occupied on 200 hall, 18 occupied on 500 hall, 15 occupied in unit, 5 occupied beds in 100 hall, 18 on 200 hall, 19 on 400 hall for a total of 87 total resident. There was 26 rooms that were semi-private and 52 residents had shared closets. An observation on 03/30/2026 at 9:15 AM revealed resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(D) Based on observation, record review, and interviews, the facility failed to ensure that the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), was accurately coded related to incontinence and an indwelling catheter for 1 (Resident 8) of 3 sampled residents. The facility census was 87. Findings are:Record review of Resident 8's MDS section H: Bladder and Bowel, dated 02/12/2026, revealed that the resident was always incontinent with urine and did not have an indwelling catheter. Record review of Resident 8's Care Plan identified use of a suprapubic catheter dated 1/18/2021. Observation on 04/01/2026 at 07:39 AM, Resident 8 in bed with catheter bag noted to be hanging on side of bed. An interview on 04/02/2026 at 9:58 AM the Minimum Data Set Coordinator (MDS Coordinator) confirmed that bowel and bladder section of the MDS was coded incorrectly. They revealed that floor nurses complete nursing MDS assessments and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09Based on observation, interview, and record review the facility failed to ensure that providers orders were followed for wound care for Resident 5. The facility had a census of 87.Findings are:A record review of Resident 5's Clinical Resident Profile revealed Resident was admitted on [DATE].A record review of Resident 5's Minimum Data Set (MDS - a federally mandated, standardized clinical assessment used in Medicare/Medicaid certified nursing homes to evaluate resident functional, medical, psychosocial and cognitive status) dated 12/17/2025 revealed Resident 5 had a Brief Interview for Mental Status (BIMS - a standardized 15-point screening tool used to assess a patient's cognitive function) of 3 indicating Resident 5 is severely cognitively impaired.A record review of Resident 5's medical record revealed the following diagnoses: Hemiplegia (severe paralysis) and Hemiparesis (partial weakness) following cerebral Infarction (stroke) affecting the left side, Infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 175 NAC 12-006.09(H)(ii)Based upon record review and interview, the facility failed to ensure that 1 (resident 3) of 1 sampled resident received proper treatment and assistive device to maintain vision. The facility census was 87 residents at the time of survey. The findings are: Record review of facility's Use of Outside Resources policy, reviewed/revised 03/2026 stated that the facility would assume responsibility for the timeliness of services provided, that arrangements would include the communication structure, and that the facility would maintain documentation and reports of recommendations of the services provided. Record review of a signed but undated Facility Services Agreement between the facility and the vendor shows that under item 2.6, the facility shall continue to assume responsibility for obtaining services that meet professional standards and principals and b) the timeliness of the services. Review of Resident 3's admission Record revealed that Resident 3 was admitted on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(H)Based on record review and interview, the facility failed to monitor and record blood pressures for the continued use of blood pressure support medications for 1 (Resident 66) of 5 sampled residents. The facility staff identified a census of 87.Findings are:Record review of facility policy titled Unnecessary Drugs-Without Adequate Indication for Use dated revised 01/2026 revealed: - 2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: -a. Dose (including duplicate therapy) -b. Duration of use -c. Indications and clinical need for medication -d. Adequate monitoring for efficacy and adverse consequences -e. Preventing, identifying and responding to adverse consequences. -3. Documentation will be provided in the resident's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2026-04-02 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5%. The facility had a census of 87.Findings are:A.A record review of Resident 69's order summary revealed the following medication orders: Acetaminophen (a pain relief tablet used to treat mild to moderate pain) 500 milligrams (mg - a unit of measurement) tablets. Take 2 tablets by mouth three times daily.Artificial tear drops (lubricating eye drops used to relieve dry, irritated eyes) instill 1 drop in both eyes daily. Wait 5 minutes before administering different eye drops.Eliquis (a prescription blood thinner) 2.5 mg tablet by mouth twice daily.Ferrous Sulfate (supplement to treat iron deficiency) (325mg tablet. Take 1 tablet by mouth every morning on Mondays and Thursdays).Furosemide (a medication that increased the output of urine) 40 mg tablet. Take 1 tablet by mouth daily.Vitamin D3 (a supplement that helps to absorb calcium) tablet 2000 Units (U - a unit of measurement). Take 1 tablet by mouth…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, interview and record review, the facility failed to ensure that 1 resident (Resident 47) of 4 residents surveyed was free of a significant medication error. The facility had a census of 87.Findings are:A record review of Resident 47's order summary revealed the following orders: Accu-Chek (a check of blood glucose levels) before meals and at bedtime. Notify MD (medical doctor) if BS (blood sugar) <60 or >450.Insulin Novolog Injectable 100/ml. Inject 12 units subcutaneously twice daily with breakfast and lunch. An observation on 3/30/2026 at 9:10 AM of MA G revealed they had checked Resident 47's blood glucose level at 9:10 AM for a measurement of 184 and administered 12 units of insulin Novolog immediately after the blood glucose check. An interview on 3/30/2026 at 9:10 AM with MA G confirmed the blood glucose monitoring was ordered for before meals and confirmed the insulin Novolog administration was scheduled for 7:00 AM. MA G confirmed they had performed the blood glucose check after Resident 47 had eaten…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-02-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number NAC 175 12-006.11(E) Nebraska Food Code 2017 4-202.16 Based on observation, interview, and record review; the facility failed to maintain the reach in refrigerator and a utility cart in a sanitary manner and failed to ensure food containers were not placed directly on the floor in the facility kitchen. This had the potential to affect 81 of 82 residents that ate food from the facility kitchen. The facility failed to ensure food items were sealed and dated on the memory care unit which had the potential to affect 16 of 16 residents that reside on the memory care unit. The facility identified a census of 82. Findings are: Observation on 02/03/25 at 7:45 AM revealed a reach-in refrigerator with white and red liquid splashes on the walls and a black utility cart with breadcrumbs and food debris on the second and third shelves. Observation on 02/04/25 at 9:10 AM revealed [NAME] B was preparing the lunch meal. [NAME] B retrieved a large container of sugar from the shelf and placed the container directly on the floor with no barrier beneath. [NAME] B measured the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19 Based on observation, and interview the facility failed to ensure that a doorbell was functional at the north entrance of the facility, this had the potential to affect 32 residents identified as independent with mobility from a facility census of 82. The facility failed to ensure wallpaper,walls, light covers,and fixtures were maintained in clean condition and good repair, in 9 (302, 303, 306, 405, 408, NW4, NW7, NW8, and NW9) of 43 occupied resident rooms. The facility failed to maintain a utility sink in good repair in the memory care unit. This had the potential to affect 15 of 16 residents that reside on the unit. The facility to ensure an exterior stair hand railing was secured to the bottom step at the entrance to the south side of the facility. This had the potential to affect 12 residents identified as self-mobile without assistive devices. The facility census was 82. The findings are: A. An interview conducted with Social Service Director (SSD) on 02-05-2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on observation, interview and record review the facility failed to ensure wound treatment orders were provided according to the practitioner's orders for 1 (Resident 331) of 4 residents sampled. The facility census was 82. The findings are: Record review of Resident 331's care plan revealed the following about the resident: -had wounds to the right lower leg -required 1-2 staff members for transfers -had a diagnosis of heart disease and seizures Record review of Resident 331's orders revealed an order for betadine (an antiseptic that is used in a medical setting to help promote healing of skin wounds) paint the second digit of the left foot and the bottom of the right foot daily. An observation of wound care on 02-04-2025 at 10:22 AM with Registered Nurse (RN) C revealed the RN painted the left foot second toe with betadine and did not paint the area to the bottom of the right foot. An interview conducted with RN C on 02-05-2025 at 2:05 PM revealed the area to the bottom of the right foot should have been painted with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on observation, interview and record review the facility failed to implement interventions to prevent falls for 1 (Resident 54) of 4 residents sampled. The facility census was 82. The findings are: Record review of Resident 54's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required extensive assistance with toileting and showering -required moderate assistance with dressing, transfers, and bed mobility Record review of Resident 54's Comprehensive Care Plan revealed Resident 54 was at risk for falls and the interventions dated 01-06-2025 to prevent falls for Resident 54 was Dycem (a non-slip product that grips on both sides to prevent sliding) to the wheelchair seat. An observation on 02-05-2025 at 7:36 AM revealed no Dycem in Resident 54's wheelchair. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(J) Based on record review and interview the facility failed to provide nutritional supplements for 1 (Resident 54) of 2 residents sampled. The facility census was 82. The findings are: Record review of Resident 54's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required extensive assistance with toileting and showering -required moderate assistance with dressing, transfers, and bed mobility. Record review of Resident 54's physician orders dated 2-05-2025 revealed an order for Med Pass 2.0 give 4 ounces 4 times a day for weight loss. Record review of Resident 54's progress notes revealed Resident 54 did not receive med pass 2.0 on 02-05-2025 at 8:00 PM due to the supplement was unavailable. An interview conducted with the Certified Dietary Manager (CDM) on 02-06-2025 at 9:15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview and record review the facility failed to ensure a medication error rate of 5% or less as evidenced by 2 errors out of 28 opportunities for error resulting in a medication error rate of 7.14%. This affected 1 (Resident 328) of 3 residents sampled. The facility census was 82. The Findings are: An observation on 02-05-2025 at 9:50 AM of Medication Aid (MA) J administering medications for Resident 328 revealed MA J administered the following: -levothyroxine 75 micrograms (mcg) administered 1 tablet -Tylenol 500 milligrams (mg) tablet administered 2 tablets -lansoprazole 3mg per 1 milliliter (ml) administered 10 ml. An interview was conducted with MA J during the observation on 02-05-2025 at 9:50 AM revealed Resident 328 had already ate breakfast. Record Review of Resident 328's physician orders dated 1-25-2025 revealed the following: -levothyroxine 75 micrograms (mcg) tablet give 1 tablet on an empty stomach. Give 30 minutes prior to the meal. -Tylenol 500 milligrams (mg) tablets give 2 tablets three times a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review and interview; the facility failed to follow Enhanced Barrier Precautions (EBP, use of gown and gloves during high-contact resident care activities) and failed to ensure supplies for wound care were not in contact with soiled items for 1 (Resident 49) of 5 sampled residents. The facility identified a census of 82. Findings are: A review of the facility policy entitled Enhanced Barrier Precautions dated 12/2023 revealed the following: -Policy Explanation and Compliance Guidelines: 1c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices. Record review of Resident 49's Quarterly Minimum Data Set (Minimum Data Set - a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-22 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NAC 175 12.006.11D Based on observation, interview and record review the facility failed to prepare food that was palatable and served at a temperature to prevent the potential for food borne illness. This had the ability to affect 71 of 72 residents that reside who ate food from the kitchen. The facility census was 72. The findings are: Record Review of Prestige Healthcare Management Food Preparation Guidelines dated 01/2024 revealed the following: -Policy- it is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. -Policy Explanation and Compliance Guidelines: The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. -Food shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes but is not limited to preparing foods as directed. -Foods and drinks shall be palatable, attractive and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include serving hot foods/drinks hot and cold food/drinks…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-22 · tag F0842 — failed to keep accurate, complete medical records — widespreadSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.16C Based on observation, interview, and record review the facility failed to ensure the residents medical records were safe from unauthorized use. This had the ability to affect all residents in the facility. The facility reports a census of 72. Findings are: An interview on 1/17/24 at 6:30 AM with Medication Aide (MA-B) revealed MA-B used their personal laptop to connect to the facility system and administer medications. MA-B reported the facility laptop does not hold a charge and needed to be continuously plugged to function. MA-B stated they deleted the facility program with residents' information before they left every day. MA -B reported no one observed them deleting the patient history from the personal lap top. MA-B confirmed MA-B could access the information of all the facility residents on their personal device. MA-B confirmed that they knew they should not use a personal electronic device to access the residents' information. An interview on 1/17/2024 at 3:44 PM with the Director of Nursing (DON) revealed that they were unaware…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-22 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NAC 175 12-006.18 Based on observation and interview the facility failed to ensure bathroom baseboards were secure in rooms [ROOM NUMBER] and failed to ensure a safe and secure sink in bathroom shared by room [ROOM NUMBER] and 308. This affected 10 of 18 sampled residents (Residents 69, 6, 9, 17, 59, 7, 22, 1, 31, and 49). The facility census was 72. The findings are: An observation with the Nursing Home Administrator (NHA) during a tour of the facility environment on 01-22-2024 from 12:00 PM to 12:30 PM revealed the following: -rooms [ROOM NUMBERS]'s sink had a visible crack in the seal between the sink and the wall and when NHA put weight on the sink it moved. -The bathrooms in rooms [ROOM NUMBER] had base boards that were not secure to the wall. An interview on 01-22-2024 at 12:30 PM with the NHA confirmed that the baseboards were loose in the bathrooms of rooms [ROOM NUMBER] and the sink in rooms [ROOM NUMBERS]'s shared bathroom was loose.
- Potential for harm · D2024-01-22 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure a Level II PASRR screen was completed after Resident's 17 and 47 were diagnosed with a serious mental illness while residing in the facility. This affected 2 (Resident 17 and 47) of 5 sampled residents. The facility identified a census of 72. Findings are. A. Record review of Resident 17's PASRR (Pre-admission Screening and Resident Review) dated 5/23/2013 reveals no mental illness was listed as the current diagnosis for this resident. The current diagnosis for Resident 17 was Mood Disorder, Anxiety Disorder, Major Depressive disorder, Pseudobulbar Affect, Psychosis not due to a substance or know physiological condition, Dementia with behavioral disturbances, Psychotic disturbance, and Mood disturbance. The SSD (Social Services Director) was interviewed on 1/18/24 at 1:30 PM. The SSD confirmed Resident 17 had a negative PASSR on 5/23/2013. The SSD confirmed Resident 17 currently does have new mental health diagnosis that would require a referral for a PASSR level II and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-22 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that 1 resident (Resident 63) had a guardian/conservator as recommended by physician. The facility reported a census of 72. Findings are: According to Resident 63 electric record Resident 63 was admitted to the facility on [DATE]. According to Resident 63's electronic record, Resident 63 had the following diagnosis - history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). A record review of Resident's 63's electronic health record revealed a Letter of Capacity written by the resident's physician and dated March 30, 2023. The letter stated the resident has severe traumatic brain injury following a motor vehicle accident. Due to the permanent brain damage, the residents' condition will never improve. The physician also stated their professional opinion was that the resident lacks the capacity to make financial or medical decisions and a guardian/conservator would be appropriate at this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-04-02 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that the daily posted nurse staffing sheets included the facility name and staffing number and actual hours worked for each shift. The facility census was 87. Findings are:A record review of the facility's Nurse Staffing Posting Information policy with a date reviewed/revised of 03/2026 revealed that the Nurse Staffing Sheet would include the facility's name. The Nurse Staffing Sheet would contain the total number and the actual hours worked by Registered Nurses, Licensed Nurses, and Nursing Assistants directly responsible for resident care each shift. A record review of the facility's PPD (Per Patient Day) Calculator v.1.0 posted nursing staff sheets dated 02/28/2026 - 03/29/2026 did not reveal the facility's name or each shifts staffing numbers or hours worked. A record review of the facility's PPD (Per Patient Day) Calculator v.1.0 posted nursing staff sheet dated 04/02/2026 with the facility's Administrator revealed did not reveal the facility's name. A record review of the facility's PPD (Per Patient Day)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2024-04-04 for 15 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PRESTIGE CARE CENTER — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.0 | ≈ chain avg |
| Health inspection | 1 of 5 | 1.3 | -0.3 vs chain |
| Staffing | 2 of 5 | 2.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 2.3 | +0.7 vs chain |
The other 2 homes this chain runs (chain average 1.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHERNS, BATSHEVA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 05/15/2023 |
| ASCHENDORF, JONATHAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2023 |
| DAVIS, SANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/13/2024 |
| KAPLAN, YISROEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/15/2023 |
| WESTER, REBECCA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/16/2019 |
CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285104. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.