Eventide Lincoln Care Center
4720 Randolph Street, Lincoln, NE 68510 · Non profit - Corporation · 197 certified beds · (402) 483-7671 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 fell from 4 to 2 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 | 18.4% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.5% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 1.4% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 6.4% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.4% | 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 | 5.5% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.4% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.6% | 19.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.6% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.1% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.8% | 20.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.1% | 75.9% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.0% | 20.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.4% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.06 | 1.81 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.99 | 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.
68.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 645 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.9% 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 292 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 68.0%CMS range 64.1–71.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 7.6–11.2 | 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 | 59.9% | 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 | 57.2% | 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 | 49.0% | 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 | 84.2% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.0% | 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 | 3.4% | 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 | 5.9%CMS range 4.0–9.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 197 beds and averages 135.3 residents a day — about 69% occupied, or roughly 62 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.32 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 4.47 hrs/resident/day on weekends vs 5.36 on weekdays — 17% thinner on weekends. RN hours go from 1.04 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2026-06-25 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 174 NAC 12-006.11 (A) Based on record review and interview, the facility failed to provide the correct therapeutic diet for one resident (Resident 3) of 5 sampled residents. The facility census was 142.Findings are: A record review of the admission Record with the printed date of June 25th, 2026 revealed that Resident 3 was admitted to the facility on [DATE] with the diagnosis of Pneumonitis due to inhalation of food and vomit, Dementia (a decline in mental abilities severe enough to interfere with daily life), and dysphagia (difficulty swallowing food or liquids). A record review of the Care Plan (Comprehensive Care Plan that is a written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed the focus: Nutrition, increased risk of suboptimal nutrition ( occurs when your body receives adequate calories but fails to get the specific balance of macronutrients, vitamins, or minerals it needs to function…
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 · D2026-06-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise post fall care plan interventions for Resident 2, Resident 5, and Resident 6 of five residents sampled . The facility reports a census of 141.A. A review of an admission Record indicated the facility admitted Resident 1 on 06/08/2026 with diagnoses that included dementia and repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2026, revealed Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. A review of Resident 1's Progress Notes revealed fall documentation for 06/08/2026 and 06/22/2026. Review of Resident 1' s Care Plan initiated on 06/08/2026, revealed the resident had a potential for falls and had fallen on 06/08/2026 and 06/22/2026. Interventions included moved Resident 1 to a room closer to the nurses station, initiated on 06/08/2026 and no new interventions were identified for 06/22/2026 fall. During an interview 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 · F2026-04-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11(E), 12-007.01(A) Based on observations, record review and interview, the facility failed to ensure foods stored were not expired, had been sealed and dated when opened, and the facility failed to prevent cross-contamination between spices and the meat products. This had the potential to affect all residents who had meals from the kitchen. The facility census was 140. Findings are: A. An observation of the kitchen on 4/27/26 at 7:30 AM revealed: In the prep refrigerator -a bag of flour tortilla opened with no date on the bag and the bag had slits on the front of the bag -Caesar dressing opened with no date on the bottle. An observation of the freezer on 4/27/26 at 7:35 AM revealed: - a bag of sweet potatoes fries opened with no date and not sealed, - a bag of mixed vegetables opened with no date, - a bag of potatoes chunks with no date on it, - a bag of Broccoli opened not sealed with no date, -a bag of chopped onions with no date on it, - a bag of celery opened not…
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 · F2026-04-30 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number NAC 175 12-006.07(C) Based on interviews and record review, the facility failed to reevaluate and revise the plan of corrective action to prevent recurrence of past performance issues. This had the potential to affect all residents residing in the facility at the time of the survey. The facility census was 140. Findings are: A record review of the facility provided, undated Current List of Active Performance Improvement Plans (PIP's) on 4.27.2026 included Client Satisfaction, Skin/Wound Documentation, Psychotropic Medications, and Falls. A record review of the facility's Statement of Deficiencies dated 12.17.2024 revealed deficient practice areas including care planning, medication errors, and infection control practices. A record review of the Medication Administration facility task for the survey ending 4.30.2026 revealed a medication error rate of 12.82%, according to Centers for Medicare and Medicaid Services (CMS), the acceptable rate for medication errors is <5%. A record review of the facility citations for the survey ending 4.30.2026 revealed…
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 before2026-04-30 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 12-006.10(D)Based on observations, record reviews, and interviews, the facility failed to ensure their medication error rate was less than 5%. There were 39 opportunities for error and five errors observed, for a total medication error rate of 12.82%. The facility census was 140.Findings are:A record review of the facility's Medication Administration and Storage policy dated 02/16/2026 revealed that medications will be considered as given at the correct time if administered one hour before or one hour after the scheduled time. A. An observation on 04/28/2026 at 8:52 PM revealed Medication Aide (MA) C administering the following medications to Resident 54: Pravastatin (a cholesterol medication) 10 mg (milligrams). A record review of Resident 54's Medication Administration Record (MAR) revealed an order for pravastatin tab 10 mg take 1 tablet by mouth every evening. The time scheduled for administration was 7:00 PM. An interview on 04/28/2026 at 8:54 PM with MA C confirmed that…
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 · E2026-04-30 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 12-006.12(D)(i)(1)Based on record reviews, observations, and interviews, the facility failed to store medications securely for Residents 5, 7, 14, 26, 43, 54, 55, 78, 83, 96, 108, and 154; and the facility failed to ensure medication carts were kept locked when unattended. The facility census was 140.Findings are: A record review of the facility's Medication Administration and Storage policy and procedure dated 02/16/2026 revealed that medications should be stored in a designated and secured (locked) area. A. An observation on 04/28/2026 at 8:04 PM revealed Medication Aide C walked away from the medication cart with the cart unlocked and multiple medication cards, topical creams, and eye drops left on top of the cart. There were no other staff around the cart. A review of the medication cards, topical creams, and eye drops left unattended on the cart revealed the following list of medications and residents: Resident 5 Sertraline (an antidepressant) 25 mg (milligrams) tablets.…
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 · D2026-04-30 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 St. 71-6022(2) Based on record review and interview, the facility failed to notify the Ombudsman (an independent official who investigates complaints against organizations-typically government agencies or specific industries like healthcare-to resolve disputes and protect rights) of the hospitalizations on 2/8/26, 3/9/26, 4/4/26 and 4/17/26 for Resident 123, and 2/27/2026 for Resident 5, out of 28 residents sampled. The facility census was 140. Findings are: Findings are: A. A record review of the Clinical Census for Resident 5 revealed an admission date of 12.15.2025. A record review of Resident 5's Minimum Data Set (MDS) (this comprehensive assessment evaluates each resident's functional capabilities) with a target date of 3.10.2026 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. A record review of the Clinical Census for Resident 5 revealed a Hospital Leave on 2.27.2026. A record review of 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 · D2026-04-30 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 12-006.09C1a Based on observation, interview, and record review; the facility failed to ensure the baseline care plan (BCP, a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) had interventions to address healthcare needs for Resident 125 who had an indwelling suprapubic urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage. The tube is inserted into the bladder through a hole in the lower abdomen) This failure had the potential to affect 1 of 2 sampled residents recently admitted to the facility. The facility census was 147. Findings are: An observation and interview on 04/27/2026 at 07:48AM revealed Resident 125 in their room with a catheter present hung at the side of their chair. They reported that they had a suprapubic catheter for many years due to medical reasons. Record review of the Order Summary Report…
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 before2026-04-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 12- 0006.09(E) (iii) Based on observations, interviews, and record review, the facility failed to care plan the services that are provided to attain or maintain the resident's highest practicable well-being for two residents (Resident 16 and Resident 110) out of eight residents sampled. The facility census was 140 at the time of the survey. Findings are: A. A record review of Resident 16's Minimum Data Set (MDS) (this comprehensive assessment evaluates each resident's functional capabilities) with a target date of 2.15.2026 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. An observation on 4.27.2026 at 10:24 AM revealed Resident 16 with an oxygen nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen to people with breathing conditions), and a nebulizer machine (a medical device that converts liquid medication into a fine mist for direct inhalation into the lungs) at the bedside. During an interview on 4.28.2026 at 7:50 AM with Medication Aide…
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 · D2026-04-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 12-006.10 Based on record review and interview, the facility failed to ensure Physicians orders were followed for one (Resident 9) of 3 sampled residents. The facility census was 140. Findings are: A record review of the admission Record with the printed date of 4/27/26 revealed that Resident 9 was admitted to the facility on [DATE] with the diagnosis of Bipolar (a chronic mental health condition characterized by intense, fluctuating mood shifts, including extreme highs (mania/hypomania) and severe lows (depression), Type 2 diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) , Essential tremors (involuntary, rhythmic shaking, most commonly in the hands during movement), Post-Traumatic Stress disorder (condition triggered by experiencing or witnessing terrifying events, such as assault, disasters, or combat), Attention-Deficit hyperactivity (characterized by persistent patterns of inattention, hyperactivity, 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 · D2026-04-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 12-006.09D3(1) Based on observation, interview, and record review the facility failed to ensure an active physician's order for the continued use of an indwelling suprapubic urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage. The tube is inserted into the bladder through a hole in the lower abdomen) and associated maintenance care was established for 1 (resident 125) of 1 resident reviewed. The facility census was 147. Findings are: An observation and interview on 04/27/2026 at 07:48AM revealed Resident 125 in their room with a catheter present hung at the side of their chair. They reported that they had a suprapubic catheter for many years due to medical reasons. Record review of the Order Summary Report (a listing of the physician orders for a resident) dated 04/28/2026 for Resident 125 revealed that they admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of bladder (occurs…
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 16 citations
- Potential for harm · Dcited before2026-04-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference number 175 NAC 12-006.18(B)(D) Based on observations, interviews and record reviews, the facility failed to ensure proper hand hygiene was completed, glove use during wound care for Resident 6, medication administration for Resident's 54 and 78, and failure to store C-pap(continuous positive airway pressure machine is the primary treatment for obstructive sleep apnea using a mask and steady airflow to keep airways open) to prevent cross contamination for 4 out of 4 sampled resident's. The facility census was 140. Findings are: A. Record review of Resident 96's electronic medical record reveal that they were admitted to the facility on [DATE] with diagnoses of encephalopathy (a disorder impacting brain function which may lead to altered mental status), epilepsy (a disorder of the brain causing seizures due to abnormal electrical activity in the brain), acute kidney failure (a sudden loss of kidney function), hypertensive heart disease with heart failure (a heart condition caused by high blood…
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 · D2025-12-31 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
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(H)Based on observations, record review and interview, the facility failed to ensure prompt response to call lights to ensure resident needs were being met for 2 (Residents 1 and 6) out of 6 sampled residents. The facility census was 131.A. A record review of admission Record revealed Resident 1 was admitted to the facility on [DATE] with the diagnosis of Cerebral Infarction (brain tissue death (necrosis) from a blocked blood vessel, cutting off oxygen and nutrients, and is the most common stroke type), Hypertensive Heart Disease (heart problems caused by long-term high blood pressure (hypertension), forcing the heart to work harder), Anxiety Disorder (mental health conditions marked by excessive, persistent fear and worry disproportionate to the situation), Major Depressive Disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities), Muscle Weakness (reduced strength, where muscle don't contract normally, caused by…
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 before2025-11-18 · 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 12-006.09(H)Based on record reviews and interviews, the facility failed to assess Resident 6 for a change of condition. This affected 1 of 4 residents sampled for changes of condition. The facility census was 132.Findings are:A record review of Resident 6's admission Record dated 09/30/2025 revealed the resident was admitted to the facility on [DATE] from an acute care hospital and discharged [DATE] to an acute care hospital. Further review of the admission Record revealed the resident had diagnoses of a right leg trimalleolar fracture (a fracture of three of the four ankle bones) that was surgically repaired, localized edema (swelling caused by fluid retention in the tissues), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF-a long-term condition in which the heart is unable to pump enough blood to meet the body's needs), an irregular heart rate, chronic kidney disease (CKD-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 · D2025-11-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12 -006.17(A)(v)Based on record reviews and interviews, the facility failed to maintain a complete and accurate medical record for 1 (Resident 6) of 6 sampled residents. The facility census was 132.Findings are:A record review of Resident 6's admission Record dated 09/30/2025 revealed the resident was admitted to the facility on [DATE] from an acute care hospital and discharged [DATE] to an acute care hospital. Further review of the admission Record revealed the resident had diagnoses of a right leg trimalleolar fracture (a fracture of three of the four ankle bones) that was surgically repaired, localized edema (swelling caused by fluid retention in the tissues), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF-a long-term condition in which the heart is unable to pump enough blood to meet the body's needs), an irregular heart rate, chronic kidney disease (CKD-a gradual loss of…
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 before2024-12-17 · 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 12.006.18(B) Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, the facility failed to ensure Yellow Zone signs were posted at the entrances to the 100 hallway, ensure [NAME] Zone signs were posted on the entrances of [NAME] and Good Houses, and ensure passive screening education was posted at Good, [NAME], and [NAME] Houses to prevent the spread of COVID-19. This had the potential to affect all residents in the facility. The facility also failed to ensure Enhanced Barrier Precautions (EBP) signs were posted for Residents 18, 54, and 120, ensure staff placed a barrier between the carpeting and staff clothing in a contact isolation room, ensure a mask was worn above the nose and below the chin in a [NAME] Zone, ensure staff wore a gown and gloves in a contact isolation room, ensure hand hygiene and gloves changes were performed between wound sites during wound care on Resident 39, ensure the staff performed hand hygiene during…
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 before2024-12-17 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.11(A)(1) Based on observation, interview, and record review; the facility failed to follow recipes when preparing resident meals. This had the potential to affect the 93 residents who received food from the kitchen. The facility identified a census of 139. Findings are: A record review of the recipe titled PU4 Hot Dog Beef 8/1 on Bun (PU4 Hot Dog on Bun) and dated 12/16/24 revealed the following instructions: -Ingredients: Hotdog Beef 8/1 on Bun, 2 each. 1/2 cup of water. 1/2 cup of Low Sodium (LS) Soup Broth Beef/Base. -Puree Bread: Tear or cut bread product into smaller pieces to facilitate blending, then add to blender or food processor. Pour in liquid. Blend until desired consistency is reached. Add additional liquid to achieve desired consistency. -Puree Filling: Place sandwich filling in blender or food processor. Add broth or other liquid. Blend until desired consistency is reached. Add additional liquid if needed to achieve desired consistency. -Sandwich Serving: Place 1 #12 scoop of the filling between 2 #12 scoops of bread. 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 before2024-12-17 · 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(B) Based on record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) related to the use of an anticoagulant (a medication used to prevent and treat blood clots in blood vessels and the heart) for 1 (Resident 30) of 5 sampled residents. The facility census was 139. Findings Are: A record review of the Resident Assessment Instrument (RAI, a manual used to provide instructions on how to complete the MDS and the care plans) User's Manual, with effective date of October 1, 2019, under N0410: Medications Received - Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as…
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 · D2024-12-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR Level II, a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) for 1 (Resident 4) of 4 sampled residents was completed as required. The census of the facility was 139. Findings are: Record review of the facility's undated Preadmission Assessment and Annual Resident Review Screening (PASARR) Policy revealed that all admissions to the facility will have a PASARR completed. For any admission with a Level II screen, the facility will follow the recommendations on the PASARR screen. Record review of Resident 4's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 11/28/24 revealed the resident was admitted to the facility on [DATE]. Record…
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 before2024-12-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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(E)(i) Based on interview and record review, the facility failed to develop and implement a resident centered Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) that accurately reflected the care needs of the resident for 1 (Resident 3) of 5 sampled residents. The facility census was 139. Findings are: Record review of facility policy titled Interdisciplinary Care Planning date reviewed 11/11/2023, revealed a comprehensive care plan will be developed by the Interdisciplinary team (IDT). The baseline careplan must include reason for admission, current medical conditions and treatments. Record review of Resident 3's list of diagnoses dated 11/15/24, revealed a primary diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident 3's baseline careplan…
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 before2024-12-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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(H)(vi)(3)(g) Based on interviews and record reviews the facility failed to obtain a physician's order for the settings of the Continuous Positive Airway Pressure (CPAP, a treatment that uses mild air pressure to keep your breathing airways open) for 1 (Resident 14) of 3 sampled residents. The census of the facility was 139. Findings are: Record review of the facility policy, Provider Orders Policy dated 1/17/14 revealed: Purpose: To define expectations and requirements for provider orders. Procedure: 1. The facility will obtain complete provider orders for each client admitted to the facility for those therapeutic and skilled services that legally require such orders. 3. All medical diagnostic and therapeutic orders, including verbal or telephone orders, will be signed by the provider and incorporated into the individual client's clinical record. Record review of Resident 14's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional…
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 before2024-12-17 · 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, record review, and interview; the facility failed to ensure a medication error rate of less than 5%. Observation of administration of 28 medications revealed 7 errors resulting in an error rate of 25%. The medication errors affected 1 (Resident 94) of 7 sampled residents. The facility census was 139. Findings are: Record review of the facility policy titled Medication Administration dated August 2016 revealed: -Medication administration schedule will be determined for all scheduled (routine) medications, -Residents will be administered medications according to the established schedule, -Medications are to be given within 1 hour before or after the scheduled administration time and are to be administered precisely as ordered. Record review of Resident 94's Quarterly Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 10/22/24 revealed an admission to the facility on 3/8/2023. In an observation on 12/12/24 at 12:08 PM 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 before2024-01-09 · 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 12-006.09B Based on record review and interview, the facility failed to code anticoagulant medication on the Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) for 1 (Resident 84) of 5 sampled residents. The facility census was 137. Findings are: A record review of Resident 84's admission Record undated revealed, an admission date of 3/24/23 with a primary diagnosis of Atrial Fibrillation (an irregular and often very rapid heart rhythm). A record review of Resident 84's Medication Administration Record (MAR) for December 2023 revealed, an order for Eliquis (anticoagulant medication) 5 milligrams (mg) take 1 tablet by mouth twice daily for Atrial Fibrillation with a start date of 10/24/23, and that the resident received Eliquis in December during the assessment time frame from 12/1/23 through 12/7/12. A record review of Resident 84's Comprehensive Care plan (CCP - written instructions needed to…
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 before2024-01-09 · 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 12-006.09D3 Based on record review and interview; the facility failed to monitor bowel movements and administer as needed medications to prevent constipation which affected 1 (Resident 71) of 1 sampled resident. The facility census was 137. Findings are: A record review of Resident 71's Clinical Resident Profile revealed, that Resident 71 was admitted on [DATE] with diagnosis' of Alzheimer's (a progressive disease that destroys memory, thinking skills, and the inability to carry out simple tasks), hypertensive heart disease (changes in the heart that cause chronic blood pressure elevation), malignant neoplasm of the uterus (cancer of the uterus), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (constant worry and restlessness) and constipation. A record review of the Quarterly MDS (Minimum Data Set) (a comprehensive assessment that measures a residents functional, medical, psychosocial, and cognitive status) dated…
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 before2024-01-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 12-006.09D6 Based on observation, record review and interview; the facility failed to rinse out a nebulizer (machine that changes medication from a liquid to a mist which is inhaled into the lungs through a mask worn over the nose and mouth) mask equipment after each use and failed to change out the nebulizer mask equipment weekly to prevent the risk of potential infection for 1(Resident 79) of 2 sampled residents. The facility census was 137. Findings are: A record review of the facility policy Respiratory Equipment Cleaning and Storage dated 12/7/2023 under nebulizer equipment revealed: 1.Nebulizer equipment is rinsed after each use and left to dry on a clean dry surface. 2.Nebulizer equipment is soaked in warm, soapy water each day and left to dry on a clean, dry surface. 3.Nebulizer equipment is exchanged weekly and prn (as needed). 4.Nebulizer equipment is stored in a clean/dry environment. A record review of Resident 79's Clinical Resident Profile revealed Resident 79 was…
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 before2023-09-27 · 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 Based on interviews and record review, the facility failed to provide prompt emergency care to 1 (Resident 1) of 3 residents sampled for emergency treatment. The facility census was 146. Findings are: A review of Resident 1's admission Record revealed the resident was admitted [DATE] with diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) after a stroke (a disruption of blood flow to part of the brain) affecting the right side of her body, heart disease, chronic kidney disease, depression, and unsteadiness on the feet. A review of Resident 1's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 07-12-2023 revealed the Brief Interview for Mental Status (BIMS - a screening measure that evaluates the resident's memory and orientation) score was 15, indicating the resident's cognition (the mental process involved in knowing, learning, and understanding things) was intact. The MDS further revealed that resident required extensive assistance (meaning…
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 · D2023-09-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 175 NAC 12-006.09D7 Based on record reviews and interviews, the facility failed to ensure that an assistive device was used in the recommended manner during a transfer for Resident 1. This resulted in a fall causing a fracture. This affected 1 of 3 resident reviewed for accidents. The facility census was 146. Findings are: A review of Resident 1's admission Record revealed the resident was admitted [DATE] with diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) after a stroke (a disruption of blood flow to part of the brain) affecting the right side of her body, heart disease, chronic kidney disease, depression, and unsteadiness on the feet. A review of Resident 1's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 07-12-2023 revealed the Brief Interview for Mental Status (BIMS - a screening measure that evaluates the resident's memory and orientation) score was 15, indicating the resident's cognition (the mental process…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EVENTIDE NEBRASKA SENIOR LIVING LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 10/10/2024 |
| BOCK, JODEE | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| BRANDT, TERRY | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| BYE, ROBERT | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 10/10/2024 |
| FISCHBACH, TYLER | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| GULBRANSON, PATRICK | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| JOHNSON, VIKKI | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 10/10/2024 |
| LARSON-CASSELTON, CINDY | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| LEE, JUDITH | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| LUNAK, BRANDON | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| SCHAFER, ERIC | Individual | CORPORATE DIRECTOR | — | since 01/01/2013 |
| SELJEVOLD, PETER | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| SWENSON, KARLA | Individual | CORPORATE DIRECTOR | — | since 10/10/2024 |
| RIEWER, JON | Individual | CORPORATE OFFICER | — | since 10/10/2024 |
| EVENTIDE | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/20/2024 |
| GUERRERO, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2026 |
| OHE, DARIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/20/2024 |
| FEIS, BETHANY | Individual | ADP OF THE SNF | — | since 04/10/2026 |
| SHIELD, CORY | Individual | ADP OF THE SNF | — | since 04/10/2026 |
CMS files one row per role, so the 22 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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.
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 285057. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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.