Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eventide Lincoln Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
Two residents with complex medical needs experienced repeated delays in staff response to call lights, with documented wait times far exceeding the facility's 5-minute expectation. Both residents reported long waits, and call light logs confirmed multiple instances of extended response times, indicating staff did not meet the facility's standard for timely care.
A resident with multiple diagnoses, including CHF, CKD, COPD, and a recent surgical repair of a right leg fracture, was not properly assessed for changes in condition. Facility staff failed to perform and document daily assessments and vital signs as required for a Medicare skilled stay, despite the resident experiencing significant weight gain, edema, and a weak pulse. Key aspects of the resident's condition were not consistently documented or communicated to the medical provider, as confirmed by staff interviews and record review.
A resident with multiple complex diagnoses, including CHF, CKD, and a recent surgical repair, did not have complete or accurate medical records maintained during a Medicare skilled stay. Required daily documentation of assessments and vital signs was missing, and critical information such as edema, neurovascular status, and respiratory assessments was often omitted. Staff interviews confirmed that the facility did not meet its own policy for daily skilled documentation or notify the medical provider of significant changes in the resident's condition.
The facility failed to implement effective infection control measures, including missing signage for designated zones and improper PPE usage. Observations revealed that staff did not adhere to Enhanced Barrier Precautions or perform adequate hand hygiene during resident care, increasing the risk of cross-contamination. These deficiencies were confirmed through staff interviews and observations.
The facility failed to follow the prescribed recipe for pureed hot dog meals, as Cook-N used a to-do list instead of the recipe, resulting in a watery consistency and omission of bread. The Culinary Director confirmed the deviation, potentially affecting the nutritional needs of 93 residents.
The facility inaccurately reported anticoagulant use in the MDS for a resident, despite the MAR and Comprehensive Care Plan showing no such medication was administered. The MDS Director confirmed the error.
A facility failed to complete a required PASRR Level II evaluation for a resident with serious mental illness, including Generalized Anxiety Disorder and Major Depressive Disorder. The initial evaluation approved the resident's stay for 180 days, but no follow-up evaluation was conducted after this period. Interviews with staff confirmed the oversight, which was against the facility's policy.
A facility failed to include a resident's chronic obstructive pulmonary disease (COPD) in their Comprehensive Care Plan (CCP), despite it being the primary diagnosis and the resident receiving respiratory therapy. The facility's policy required the inclusion of current medical conditions in the care plan, but this was not adhered to, as confirmed by the MDS Director.
A facility failed to obtain a physician's order for CPAP settings for a resident with chronic respiratory conditions. Despite the resident's need for respiratory care, the electronic medical record lacked specific directions for CPAP use, which was confirmed by the facility administrator.
A facility failed to maintain a medication error rate below 5%, with a 25% error rate observed. A resident received several medications late, contrary to the facility's policy, due to the resident's preference to sleep late. Medications were not administered according to specific instructions, such as Levothyroxine not being given on an empty stomach and Potassium not being given with food. An LPN confirmed the errors in administration timing and medication combinations.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Respond Promptly to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for two residents, resulting in unmet resident needs. For one resident with multiple complex diagnoses, including cerebral infarction, hypertensive heart disease, anxiety disorder, major depressive disorder, muscle weakness, urinary retention, bowel incontinence, and hemiplegia, both interviews and call light logs confirmed repeated delays in staff response. The resident reported that call lights took a long time to be answered, and direct observation showed a call light remaining on for 15 minutes before staff responded. Review of call light logs revealed multiple instances where the call light was left on for extended periods, ranging from 17 to 54 minutes on various dates. Another resident, diagnosed with Parkinson's disease and assessed as cognitively intact, also reported waiting up to half an hour or more for call light responses. Review of this resident's call light event log showed numerous occasions where the call light remained on for periods ranging from 18 to 46 minutes. Both residents' experiences were corroborated by documentation and interviews, confirming that staff did not meet the facility's stated expectation of responding to call lights within 5 minutes. The facility's policy, last revised in August, requires staff to respond to call lights in a timely manner, with the Executive Director and a Registered Nurse both confirming the expectation of a 5-minute response time. Despite this policy, the documented delays in responding to call lights for these two residents demonstrate a failure to meet the established standard of care.
Failure to Assess and Document Change in Condition for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to properly assess a resident for a change in condition, specifically neglecting to perform and document daily assessments and vital signs as required for a Medicare skilled stay. The resident, who had multiple complex diagnoses including a surgically repaired right leg trimalleolar fracture, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure, was admitted from an acute care hospital and later discharged back to a hospital. Documentation revealed that the resident experienced significant weight gain (11.4 pounds in ten days), edema in both legs, and a weak pulse in the right foot, but there was no evidence that these changes were communicated to the medical provider or that appropriate assessments were performed and recorded daily. Review of the resident's progress notes and vital signs showed inconsistent and incomplete documentation. Several nursing and Medicare notes failed to address key aspects of the resident's condition, such as edema, neurovascular status of the right foot, and the presence or condition of the cast or splint. The facility's own policy required daily documentation for skilled Medicare residents, including full assessments and vital signs, but this was not consistently done. The resident's weight record indicated a notable increase, yet there was no documentation of provider notification regarding this change. Interviews with facility staff, including a registered nurse, resident care manager, provisional administrator, and director of nursing, confirmed that the required daily assessments and documentation were not present in the electronic health record. Staff acknowledged that, given the resident's diagnoses, assessments should have included respiratory status, oxygen saturation, edema, and neurovascular checks of the right foot at least daily, but these were not documented. The deficiency was identified through record review and staff interviews, which verified the lack of appropriate assessment and documentation for the resident's change in condition.
Failure to Maintain Complete and Accurate Medical Records for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who was admitted following a right leg trimalleolar fracture repair and had multiple complex diagnoses, including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure. Documentation reviews revealed that required daily assessments and vital signs were not consistently recorded during the resident's Medicare skilled stay. Specifically, there were gaps in documentation regarding the resident's edema, neurovascular status of the right foot, and the presence or condition of the cast or splint, despite orders for regular monitoring and the resident's high-risk medical profile. Progress notes and assessments frequently omitted critical information such as edema, neurovascular checks, and respiratory status, even though the resident experienced significant weight gain and changes in condition. The medical provider was not notified of the resident's weight gain, and there was no evidence of daily skilled documentation as required by facility policy and professional standards. The facility's own policy required daily documentation for Medicare skilled residents, including full assessments and vital signs, which was confirmed by staff interviews as not being met in this case. Interviews with nursing staff, the Resident Care Manager, the Provisional Administrator, and the Director of Nursing confirmed the lack of required documentation and assessments. The absence of daily monitoring and communication with the medical provider regarding significant changes in the resident's condition, such as weight gain and edema, contributed to the incomplete and inaccurate medical record. The deficiency was substantiated by both record review and staff interviews.
Infection Control Deficiencies in Signage and PPE Usage
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the absence of appropriate signage and personal protective equipment (PPE) usage in designated zones. Observations revealed that Yellow Zone signs were not posted at the entrances to the 100 hallway, and [NAME] Zone signs were missing at the entrances of [NAME] and Good Houses. Additionally, passive screening education was not visible at the entrances to [NAME], [NAME], and Good Houses, and staff were observed not wearing masks in these areas. Interviews confirmed that these zones were designated due to positive COVID-19 cases, yet the necessary precautions were not communicated or enforced. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Observations showed that EBP signs were not present in the rooms of residents with visible urinary catheter bags, and staff did not use appropriate PPE during high-contact care activities. Furthermore, during wound care for Resident 39, staff did not perform hand hygiene or change gloves between wound sites, increasing the risk of cross-contamination. Similar lapses were noted during catheter care for Resident 114, where contaminated gloves were used to obtain cleansing wipes, and hand hygiene was not performed for the recommended duration. Additional deficiencies were observed in the facility's adherence to contact precautions and hand hygiene protocols. Staff entered contact isolation rooms without wearing the required gowns and gloves, and hand hygiene was not performed for the required 20 seconds. These failures were confirmed through interviews with staff and the facility's Infection Preventionist, highlighting a systemic issue in the facility's infection control practices.
Failure to Follow Recipe for Resident Meals
Penalty
Summary
The facility failed to adhere to the prescribed recipe for preparing resident meals, specifically the pureed hot dog meal. During an observation of meal preparation, Cook-N was seen using a to-do list instead of the recipe provided for the meal. Cook-N used water from the pot where hot dogs were boiling and added it to a blender with hot dogs and a liquid thickener, without measuring the water or using the recipe instructions. This resulted in a watery liquid consistency for the pureed hot dogs, and no bread or bun was used as required by the recipe. The Culinary Director confirmed that Cook-N did not prepare any buns, did not measure the water used, and did not have the recipe out during meal preparation. This deviation from the recipe had the potential to affect the nutritional needs of the 93 residents who received food from the kitchen, as the facility census was 139. The failure to follow the recipe could impact the quality and consistency of the meals provided to the residents.
Inaccurate MDS Reporting for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident regarding the use of anticoagulant medication. A review of the Resident Assessment Instrument (RAI) User's Manual indicated that the MDS should accurately reflect the number of days an anticoagulant was received by the resident during a 7-day look-back period. However, for one resident, the MDS inaccurately indicated the use of an anticoagulant, despite the Medication Administration Record (MAR) for September and October showing no use of such medication. Additionally, the resident's Comprehensive Care Plan did not document the use of an anticoagulant for cardiovascular status. An interview with the MDS Director confirmed that the anticoagulant should not have been marked for this resident.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure the completion of a Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident, as required. The resident, who was admitted to the facility, had a history of serious mental illness, including Generalized Anxiety Disorder, Major Depressive Disorder, and Bipolar Disorder. The initial PASRR Level II evaluation, conducted in March 2024, confirmed the need for nursing facility services and approved the resident's stay for 180 days. However, after the 180-day period elapsed, no additional PASRR Level II evaluation was conducted. Interviews with facility staff, including a social worker and the administrator, confirmed that the PASRR Level II evaluation was due in September 2024 but was not completed. This oversight indicates a failure to adhere to the facility's policy, which mandates that all admissions with a Level II screen follow the recommendations on the PASRR screen. The facility's census at the time was 139, and this deficiency was identified for one of the four sampled residents.
Failure to Include COPD in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered Comprehensive Care Plan (CCP) that accurately reflected the care needs of a resident with chronic obstructive pulmonary disease (COPD). The facility's policy required the Interdisciplinary team (IDT) to develop a comprehensive care plan that includes the reason for admission, current medical conditions, and treatments. However, the baseline care plan and the CCP for the resident did not include the diagnosis or interventions for COPD, despite it being the primary diagnosis. The resident had been receiving respiratory therapy four times in the prior seven days, indicating the need for such interventions. This deficiency was confirmed during an interview with the MDS Director, who acknowledged that the COPD diagnosis should have been included in both the baseline care plan and the CCP.
Failure to Obtain Physician's Order for CPAP Settings
Penalty
Summary
The facility failed to obtain a physician's order for the settings of the Continuous Positive Airway Pressure (CPAP) for one of the sampled residents, identified as Resident 14. This deficiency was identified through interviews and record reviews. The facility's policy, dated 1/17/14, requires complete provider orders for therapeutic and skilled services that legally require such orders. However, a review of Resident 14's electronic medical record revealed no physician's order for CPAP settings, despite the resident's need for respiratory care. Resident 14 had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, obstructive sleep apnea, and mild persistent asthma. The resident's physician orders dated 12/12/24 included the use of CPAP/BiPAP at home or hospital settings, but no specific directions for the CPAP settings were provided. An interview with the facility administrator confirmed the absence of a physician's order for the CPAP settings, acknowledging that such an order should have been in place.
Medication Administration Errors Result in 25% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by a 25% error rate observed during the administration of 28 medications, with 7 errors affecting one resident. The facility's policy on medication administration, dated August 2016, requires medications to be administered according to a set schedule, within one hour before or after the scheduled time, and precisely as ordered. However, during an observation, it was noted that the Medication Administration Record (MAR) for a resident was entirely red, indicating that all morning medications were late. The resident's MAR showed several medications scheduled for 6:00 AM, including Metoprolol Succinate, Levothyroxine, Furosemide, Cephalexin, Potassium chloride, Citalopram, and Amlodipine Besylate. These medications were administered late at 12:25 PM, and not according to the specific instructions, such as Levothyroxine not being given on an empty stomach and Potassium not being given with food. The Medication Aide (MA) admitted to administering the medications late because the resident preferred to sleep late. An LPN confirmed that Levothyroxine and Potassium should not have been given together and that all morning medications were administered late.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gateway Vista | 0.8 mi | ★★★★★ | 20 | 0 |
| St. Jane De Chantal | 1.1 mi | ★★★★★ | 27 | 0 |
| Ambassador Health Of Lincoln | 1.2 mi | ★★★★★ | 3 | 0 |
| Eastmont | 1.4 mi | ★★★★★ | 6 | 0 |
| Holmes Lake Rehabilitation & Care Center | 1.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.