Prestige Care Center of Nebraska City

In the surveyor’s words

From the most serious findings on record at Prestige Care Center of Nebraska City, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 10, 2024

  Licensure 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. Findings are: A. A review of Resident 3's Face Admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure [a chronic condition in which the heart is unable to pump blood efficiently enough to meet the body's needs]. A review of Resident 3's admission orders dated 7/31/24 revealed order for daily weights. […]

• Actual harm, isolatedF686Jun 9, 2022

  LICENSURE 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. Findings are: Record review of Resident 40's Admission/Readmission Nursing Evaluation ([NAME]) dated 5-06-2022 revealed had [CONDITION(S)] and a [CONDITION(S)]. According to the [NAME] dated 5-06-2022 Resident 40 was evaluated as a low risk for the development of a pressure ulcer. […]

• Actual harm, isolatedF697Jun 9, 2022

  Licensure 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. The findings are: A review of a wound assessment for Resident 40 dated 7/28/22 and completed by DNP K (Doctor of Nursing Practice) revealed Resident 40 had an unstageable pressure ulcer to their left heel that measured 2.31 cm (centimeters) x 3.03 cm with a depth of 0.2 cm. DNP K documented that the wound had deteriorated since the last evaluation on 7/14/22. An observation on 8/18/22 at 8:45 AM revealed RN A (Registered Nurse) provided wound care to a pressure ulcer on Resident 40's left heel. […]

• Actual harm, isolatedF697Jun 9, 2022

  Licensure 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. The findings are: A review of a wound assessment for Resident 40 dated 7/28/22 and completed by DNP K (Doctor of Nursing Practice) revealed Resident 40 had an unstageable pressure ulcer to their left heel that measured 2.31 cm (centimeters) x 3.03 cm with a depth of 0.2 cm. DNP K documented that the wound had deteriorated since the last evaluation on 7/14/22. An observation on 8/18/22 at 8:45 AM revealed RN A (Registered Nurse) provided wound care to a pressure ulcer on Resident 40's left heel. […]

• Actual harm, isolatedF760Jun 9, 2022

  Licensure 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility had a total census of 36 residents. The findings are: An observation on 8/18/22 at 11:40 AM revealed Resident 26 sat in a recliner in their room with their feet up in a reclined position. Resident 26 did not respond or open their eyes to voice or when NA H (Nurse Aide) repositioned the resident in their chair. In an interview on 8/18/22 at 11:40 AM, NA H reported Resident 26 had declined significantly since being diagnosed with COVID-19. NA H reported Resident 26 used to run in the hallways, but now wasn't even able to walk. […]