Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eventide Crete during CMS and state inspections, most recent first.
A resident with Parkinson's disease, dementia with mood/psychotic disturbance, hallucinations, and delusional disorder had a prior PASARR identifying SMI and Major Depression, but no new PASARR was completed after additional mental health diagnoses were added. Record review and Social Services interview confirmed that the resident developed new delusional disorder, hallucinations, and adjustment disorder with mixed anxiety and depressed mood, yet the required PASARR review was not done despite the facility policy calling for a new screen with significant mental health changes.
The facility failed to complete a discharge summary for a resident who was sent to the hospital for critically high K+ levels. The resident had HF, pericardial effusion, CAD, acute-on-chronic kidney disease, and HTN. The resident's representative was given the bed-hold policy and declined it, and the MDS coordinator confirmed the discharge summary had not been done.
The facility failed to maintain proper sanitation and hygiene practices, including dishwashing temperatures, cleanliness of range hoods and ice machines, and hand hygiene. Observations revealed substandard wash temperatures, unclean equipment, and improper handwashing techniques. Additionally, food was transported uncovered through hallways, posing a risk of contamination.
A resident with multiple health issues, including heart failure and dementia, experienced a decline due to pneumonia, requiring increased assistance and oxygen use. The facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14 days, as confirmed by staff interviews.
The facility failed to update care plans for two residents. One resident's care plan was not revised to reflect a change to Do Not Resuscitate (DNR) status, while another resident's care plan was not updated after the removal of a urinary catheter. These deficiencies were confirmed through interviews with nursing staff.
A facility failed to ensure proper hand hygiene during catheter care for a resident with a catheter. A medical assistant did not perform hand hygiene before donning gloves or between glove changes while providing care, contrary to the facility's hand hygiene policy. The assistant only washed their hands after completing the procedure, which was confirmed as incorrect practice by both the assistant and the Director of Nursing.
Failure to Complete PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a PASARR assessment for one resident after new mental health diagnoses were added following admission, to determine whether the resident was receiving the necessary services indicated for the disorder. Resident 28 was admitted with Parkinson's disease, dementia with mood/psychotic disturbance, adjustment disorder with mixed anxiety and depressed mood, hallucinations, and delusional disorders. The resident's prior PASARR, dated 3/23/23, identified SMI and marked the mental disorder as Major Depression, and no additional PASARR was documented after that review. Record review showed that Resident 28 received new diagnoses of Delusional Disorder on 12/5/24, Hallucinations on 1/13/25, and Adjustment Disorder with mixed anxiety and Depressed Mood on 3/6/25. The facility's policy stated that a new PASARR screen would be completed upon a significant change in mental health or with a newly diagnosed mental illness/disorder, intellectual disability, or related condition for a Level 2 review. Social Services confirmed in interview that the last PASARR was completed in 3/23 and that a new PASARR should have been completed with each new mental illness/disorder diagnosis, but it was not done.
Missing Discharge Summary and Bed-Hold Documentation
Penalty
Summary
The facility failed to document a recapitulation, or complete summary of the resident stay from admission to discharge, for one resident. Resident 38 was admitted with diagnoses including heart failure, pericardial effusion, coronary artery disease, acute-on-chronic kidney disease, and hypertension. The resident was later discharged to the hospital due to critically high potassium levels, and the resident's representative was present when the bed hold policy was provided and declined it. A review of the facility's discharge policy stated that team leaders will complete the discharge checklist and that RN/LPN staff will complete a discharge progress note. During interview, the MDS coordinator confirmed that a discharge summary had not been completed for Resident 38 and stated that it was not thought to be necessary because the resident was sent to the hospital; the coordinator also confirmed awareness that the representative declined the bed hold policy and that the resident was discharged from the facility.
Deficiencies in Sanitation and Hygiene Practices
Penalty
Summary
The facility failed to ensure that the dishwashing machine in House 2 reached the required water temperature for proper sanitation, as per the 2017 Nebraska Food Code. Observations revealed that the wash temperatures were consistently below the required 150°F, with recorded temperatures ranging from 120°F to 134°F. The facility's policy required monitoring and logging of dishwashing temperatures, but logs were incomplete, and there was no indication of which machine was checked. Interviews confirmed that staff did not consistently monitor or report low temperatures, and the dishwashing machine was not checked until the cook arrived at 10:00 AM, leaving breakfast cleanup unsupervised in terms of temperature checks. The facility also failed to maintain cleanliness in nonfood-contact surfaces, such as range hoods and ice machines, which were observed to have accumulated substances. The exhaust hoods in both Houses 1 and 2 had a dark brown substance, and the ice machines had greenish and blackish substances on their deflectors. The Registered Dietician confirmed the need for cleaning, and the facility's cleaning schedule was not adhered to, as indicated by unmarked tasks on the schedule. Additionally, the facility did not implement proper hand hygiene practices, as observed with Cook-B, who did not wash hands for the required duration and used the same paper towel to turn off the faucet. Food was also transported uncovered through hallways, as seen with containers of peaches carried to residents. These practices were confirmed by staff interviews, indicating a lack of adherence to the facility's hand hygiene and food transport policies.
Failure to Complete Timely SCSA for Resident with Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within 14 days of a significant change in condition for a resident. The resident, who was admitted with diagnoses including heart failure, chronic kidney disease, poor circulation, dementia, and a history of a heart attack, experienced a decline in condition due to pneumonia. This decline was noted to have started in May 2024, and the resident had not returned to their baseline condition by the time of the report. The resident's functional abilities showed a decline, as evidenced by the need for increased assistance in activities of daily living (ADLs) such as dressing, transferring, and mobility. The resident also began using oxygen, which was not required in the previous assessment. Despite these changes, the facility did not complete an SCSA within the required timeframe, which is mandated when a resident experiences a significant change in condition that does not resolve within two weeks. Interviews with the Director of Nursing and the Registered Nurse/MDS Coordinator confirmed that the resident had not returned to their baseline and that an SCSA should have been conducted. The failure to perform the assessment in a timely manner was acknowledged by the staff, indicating a lapse in adhering to regulatory requirements for monitoring and assessing significant changes in resident conditions.
Failure to Revise Care Plans for Code Status and Catheter Removal
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident 22 after a change in the resident's code status. Resident 22 was admitted to hospice services and had a Do Not Resuscitate (DNR) document signed by the resident's Power of Attorney and the medical provider. However, the care plan still indicated a 'Full Code' status, which was not updated to reflect the resident's current wishes. This discrepancy was confirmed during an interview with a registered nurse. Similarly, the facility did not update the care plan for Resident 33 after the removal of a urinary catheter. Resident 33 had a history of prostate cancer and urinary retention, which initially required catheterization. The catheter was removed following a cystoscopy appointment, but the care plan continued to list interventions related to the presence of a catheter. This oversight was also confirmed during an interview with a registered nurse. These deficiencies affected two of the twelve residents reviewed for care plan revisions, indicating a failure to maintain accurate and up-to-date care plans that reflect the current medical status and treatment preferences of the residents. The facility census at the time was 34 residents.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during catheter care for a resident, identified as Resident 19. The resident, who had a catheter as indicated by the Minimum Data Set (MDS) assessment, was observed receiving catheter care from a medical assistant (MA-F). During the procedure, MA-F donned a surgical mask, gloves, and gown without performing hand hygiene prior to putting on gloves. MA-F proceeded to pull down the resident's sweatpants and open the brief without changing gloves or performing hand hygiene. After completing peri care and catheter care, MA-F assisted the resident to their left side, removed the dirty brief, applied a clean brief, and pulled up the sweatpants, again without changing gloves or performing hand hygiene. The observation further revealed that MA-F changed gloves before using a graduate container to empty the catheter drainage bag and cleaned the catheter drainage bag opening with an alcohol wipe. It was only after these tasks that MA-F washed their hands with soap and water for 20 seconds. Interviews with MA-F and the Director of Nursing (DON) confirmed that hand hygiene should have been performed prior to donning gloves, mask, and gown, and between each glove change. The facility's hand hygiene policy, dated 9/25/19, specifies that handwashing should occur when moving from a contaminated body site to a clean body site during client care and after removing gloves, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Crete
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilber Care Center | 9.5 mi | ★★★★★ | 4 | 0 |
| Milford Meadows Care Center | 11.1 mi | ★★★★★ | 1 | 0 |
| Heartland Ridge Care Center | 15.7 mi | ★★★★★ | 0 | 0 |
| Eventide Williamsburg | 16.6 mi | ★★★★★ | 10 | 0 |
| Emerald Nursing & Rehab Lancaster Llc | 16.8 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.