Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prestige Care Center Of Plattsmouth during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in the kitchen and memory care unit, affecting 81 of 82 residents. Observations revealed unsanitary conditions, including a refrigerator with liquid splashes, a utility cart with food debris, and food containers placed directly on the floor. Open, unsealed bags of cereal were also found in the memory care unit. The Certified Dietary Manager confirmed these issues and the lack of adherence to the cleaning schedule.
The facility failed to maintain a functional doorbell at the north entrance, affecting 32 residents with independent mobility. Additionally, issues such as holes in walls, stained toilets, and unsecured handrails were observed in various areas, impacting resident safety and comfort. The Maintenance Director confirmed these issues with no active work orders to address them.
A facility failed to follow a practitioner's wound treatment orders for a resident with heart disease and seizures. The resident's care plan required betadine application to specific areas on the feet, but a nurse only treated one area. Interviews confirmed the oversight, which contradicted the facility's wound treatment policy.
A facility failed to implement fall prevention interventions for a resident with severe cognitive impairment. The care plan required Dycem on the wheelchair seat, but observations revealed its absence. Staff interviews confirmed the intervention was not implemented, despite the facility's policy for individualized care based on risk assessment.
A resident with severe cognitive impairment did not receive a prescribed nutritional supplement due to staff unawareness and miscommunication, despite the supplement being available. The facility's policy on maintaining nutritional status was not followed, leading to a deficiency in care.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 7.14% error rate. A resident received levothyroxine and lansoprazole at incorrect times, contrary to physician orders. The facility's policy requires adherence to physician orders and professional standards, which was not followed in this instance.
A facility failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with cognitive impairments and an open lesion. RN A did not wear a gown as required and placed wound care supplies on soiled surfaces without barriers. The DON confirmed the need for barriers and gown use during such procedures.
Sanitation Deficiencies in Kitchen and Memory Care Unit
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and memory care unit, which had the potential to affect 81 of 82 residents who consumed food prepared by the facility. Observations revealed unsanitary conditions, including a reach-in refrigerator with liquid splashes and a utility cart with breadcrumbs and food debris. Additionally, food containers were placed directly on the floor without a barrier, and open, unsealed bags of cereal were found in the memory care unit. These actions were confirmed by the Certified Dietary Manager (CDM), who acknowledged the presence of unsanitary conditions and the lack of adherence to the cleaning schedule. The facility's sanitation policy required daily inspections of food service areas, including refrigerators and storage areas, and weekly inspections by the dietary manager to ensure compliance with sanitation regulations. However, the CDM confirmed that the cleaning schedule had not been filled out, indicating a failure to adhere to the established sanitation program. The Nebraska Food Code also mandates that nonfood-contact surfaces be designed for easy cleaning, which was not observed in the facility's practices.
Facility Deficiencies in Maintenance and Safety
Penalty
Summary
The facility failed to ensure a functional doorbell at the north entrance, which had the potential to affect 32 residents identified as independent with mobility. During an observation, it was noted that the doorbell at the main entrance did not sound when pushed, confirmed by the Receptionist and the Administrator in Training, who stated that the doorbell chime was not plugged in. This deficiency was observed on a day when the temperature outside was 26 degrees Fahrenheit, potentially impacting residents' ability to re-enter the facility safely. Additionally, the facility did not maintain the cleanliness and repair of various areas, including wallpaper, walls, light covers, and fixtures in nine resident rooms. Specific issues included holes in walls, stained toilet bases, cracked caulking, and missing light covers. In the memory care unit, the utility sink was in disrepair, and the wallpaper was torn. Furthermore, the handrail to the exterior steps beside the south entrance was rusted and not secured, affecting 12 residents identified as self-mobile without assistive devices. The Maintenance Director confirmed these issues and acknowledged that there were no active work orders to address them.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility failed to ensure that wound treatment orders were followed according to the practitioner's instructions for a resident with wounds. The resident, who had wounds on the right lower leg and required assistance for transfers, had a diagnosis of heart disease and seizures. The practitioner's order specified that betadine should be applied to the second digit of the left foot and the bottom of the right foot daily. However, during an observation of wound care, a registered nurse applied betadine only to the left foot's second toe and neglected to treat the bottom of the right foot. Interviews with the registered nurse and the wound nurse confirmed that the order was not fully executed as prescribed. The facility's policy on wound treatment management emphasized the importance of providing evidence-based treatments in accordance with physician orders, which was not adhered to in this instance.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 0. The resident required extensive assistance with toileting and showering, and moderate assistance with dressing, transfers, and bed mobility. The resident's care plan, dated January 6, 2025, specified the use of Dycem on the wheelchair seat to prevent falls. However, observations on February 5 and 6, 2025, revealed that Dycem was not present on the resident's wheelchair. Interviews with facility staff, including a Nursing Assistant (NA) and the Director of Nursing (DON), confirmed that the intervention of Dycem was not implemented as per the care plan. The NA reported alternative fall interventions, such as gripper socks and non-skid strips, but did not acknowledge the need for Dycem in the wheelchair. The facility's fall prevention policy requires individualized care and services based on each resident's risk assessment, but the lack of Dycem in the wheelchair indicates a failure to adhere to the resident's comprehensive care plan.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for Resident 54, who was assessed with severe cognitive impairment and required assistance with daily activities. The resident had a physician's order for Med Pass 2.0, a nutritional supplement, to be given four times a day due to weight loss. However, the supplement was not administered on the evening of February 5, 2025, because it was reportedly unavailable, despite the facility having it on hand. Further investigation revealed that on the morning of February 6, 2025, the supplement was again not given because the RN on duty was unaware of what Med Pass 2.0 was. Interviews with the Certified Dietary Manager and the Director of Nursing confirmed the oversight, and an observation showed that the supplement was available in the refrigerator at the nurse's station. The facility's policy on weight monitoring emphasized maintaining residents' nutritional status, but the failure to administer the supplement as ordered indicated a lapse in following this policy.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 7.14% error rate resulting from 2 errors out of 28 opportunities. This deficiency affected one resident, identified as Resident 328, out of a sample of three residents, with a total facility census of 82. During an observation, Medication Aid (MA) J administered medications to Resident 328, including levothyroxine, Tylenol, and lansoprazole. However, the administration of levothyroxine and lansoprazole did not comply with the physician's orders. Levothyroxine was supposed to be given on an empty stomach, 30 minutes before a meal, but was administered after the resident had already eaten breakfast. Lansoprazole was to be given with breakfast, but the timing of its administration was not aligned with this requirement. An interview with MA J confirmed the errors in the timing of medication administration. The facility's medication administration policy, dated January 2025, requires medications to be administered as ordered by the physician and in accordance with professional standards of practice. The policy emphasizes verifying the resident's name, medication name, form, dose, route, and time against the medication administration record. The failure to adhere to these guidelines resulted in the observed medication errors, contributing to the facility's non-compliance with the required medication error rate.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during the care of a resident, identified as Resident 49, who required wound care. The facility's policy mandates the use of gowns and gloves during high-contact resident care activities, which was not followed by Registered Nurse (RN) A. During an observation, RN A entered the resident's room without wearing a gown, despite signage indicating the requirement for gown and glove use. Additionally, RN A placed a stack of washcloths directly on the bed linens and a basin of soapy water on the floor without any barrier, which is against the facility's infection control policy. Resident 49, who had unclear speech and cognitive impairments, was dependent on staff for care and had an open lesion requiring daily wound treatment. The resident's physician orders specified cleaning the left shoulder open area with soap and water and applying a border gauze daily. Despite these orders and the resident's condition, RN A did not follow proper infection control procedures, as confirmed by both RN A and the Director of Nursing (DON). The DON acknowledged that wound supplies should be placed on a barrier and that a gown should have been worn during the wound treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plattsmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glen Haven Village | 9.2 mi | ★★★★★ | 2 | 0 |
| Hillcrest Health & Rehab | 9.4 mi | ★★★★★ | 5 | 0 |
| Hillcrest Country Estates-cottages | 10.9 mi | ★★★★★ | 0 | 0 |
| Hillcrest Shadow Lake Llc | 11.8 mi | ★★★★★ | 4 | 0 |
| Brookestone Of Papillion | 12.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.