Prestige Care Center of Nebraska City
1420 North 10th Street, Nebraska City, NE 68410 · Otoe County · 64 certified beds · avg 41 residents/day · certified since Jun 25, 1991
Part of chain: PRESTIGE CARE CENTER (3 facilities, chain avg rating 1.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 10, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 9, 2022 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 23, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 9, 2022 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 23, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 9, 2022 · F-0760
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 23, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (44)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 23, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 5, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. · from a complaint |
| Dec 17, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 17, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · from a complaint |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 22, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 22, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Sep 22, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 13, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Nov 13, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Nov 13, 2024 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Sep 10, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Sep 14, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Sep 14, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 14, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Sep 14, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 9, 2022 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 9, 2022 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jun 9, 2022 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jun 9, 2022 | F · Potential for harm, facility-wide | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 9, 2022 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jun 9, 2022 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 9, 2022 | F · Potential for harm, facility-wide | The facility did not perform required COVID-19 testing on residents and staff. |
| Jun 9, 2022 | F · Potential for harm, facility-wide | The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 9, 2022 | E · Potential for harm, repeated | The facility did not provide bedrooms with required basics: a window to the outside, a room at or above ground level, adequate bedding, furniture that fits the resident's needs, or enough closet space. |
| Jun 9, 2022 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jun 9, 2022 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 9, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 9, 2022 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Jun 9, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 21 | 3 | G ▲ |
| 2023 | 4 | 0 | F |
| 2024 | 5 | 1 | G ▲ |
| 2025 | 9 | 0 | E |
| 2026 | 5 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $15,625.
| Date | Type | Amount / length |
|---|---|---|
| Sep 10, 2024 | Fine | $15,625 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.51 | 4.33 | 3.95 | bottom 18% in Nebraska; bottom 37% in the U.S. |
| Registered Nurse hours | 0.46 | 0.72 | 0.69 | bottom 19% in Nebraska; bottom 31% in the U.S. |
| Weekend total nurse staffing | 3.36 | 3.79 | 3.50 | bottom 30% in Nebraska; top 49% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.41 | 0.47 | 0.48 | top 49% in Nebraska; top 46% in the U.S. |
| Total nursing staff turnover (%) | 76.6 | 48.7 | 45.8 | bottom 6% in Nebraska; bottom 3% in the U.S. |
| RN turnover (%) | 100.0 | 44.1 | 42.9 | bottom 1% in Nebraska; bottom 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.41, RN 0.45, weekend 3.27. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Cherns, Batsheva | Individual | 5% or Greater Direct Ownership Interest | 5% | 05/15/2023 |
| Aschendorf, Jonathan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2023 |
| Aschendorf, Jonathan | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2023 |
| Aschendorf, Jonathan | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2023 |
| Clifton, Stephanie | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/13/2025 |
| Clifton, Stephanie | Individual | ADP of the SNF | NOT APPLICABLE | 10/13/2025 |
| Kaplan, Yisroel | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/15/2023 |
| Wester, Rebecca | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2022 |
| Wester, Rebecca | Individual | ADP of the SNF | NOT APPLICABLE | 02/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| The Ambassador Nebraska City, INC | 0.5 mi | Nebraska City, NE | ★★★★★ | 5/5 | |
| The Ambassador Sidney INC | 11.7 mi | Sidney, IA | ★★★★☆ | 4/5 | |
| Good Samaritan Society - Syracuse | 17.4 mi | Syracuse, NE | ★★★★☆ | 4/5 | |
| Tabor Manor Care Center | 17.4 mi | Tabor, IA | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 285109.