Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Prairie Commons Care Center during CMS and state inspections, most recent first.
Two residents had discrepancies between their signed advance directives and the code status listed in the EMR, care plans, and staff reference materials. Staff relied on inconsistent sources to determine code status, leading to confusion and the potential for care that did not align with residents' wishes. The issue was confirmed by nursing leadership and involved residents with complex medical histories.
The facility exceeded the acceptable medication error rate, with multiple errors involving late administration and omission of medications. Errors occurred when an LPN administered a Parkinson's medication late to a resident, gave all morning medications late to another due to incorrect EMAR times, and failed to give a scheduled dose of pantoprazole to a third resident. Staff and pharmacy were aware of the EMAR timing issues but did not correct them promptly, resulting in a high error rate.
An LPN assisted multiple residents during meal service, including helping a resident who eats with their hands and handling soiled clothing protectors, without performing hand hygiene between contacts. The LPN only used alcohol-based hand sanitizer after assisting several residents, contrary to facility policy, as confirmed by interviews with the ADON and the LPN.
Two residents were not given the required SNF ABN (CMS-10055) and NOMNC (CMS-10123) forms when discharged from Medicare Part A skilled services, despite having benefit days remaining. Facility staff could not locate documentation of these notices, and interviews revealed that changes in social services contributed to lapses in providing the required notifications.
A resident with an unstageable pressure ulcer on the left heel did not have required weekly wound evaluations and measurements documented in the EMR, despite facility policy and care plan directives. Multiple record reviews and staff interviews confirmed the absence of necessary wound assessment documentation, preventing proper monitoring of the wound's healing status.
A resident with multiple health conditions experienced delays in call light response and did not receive routine bathing as per their preference and facility standards. The resident waited 23 minutes for assistance, and records showed only two baths or showers in a month. The facility lacked a standard for call light response times, and the DON confirmed the resident did not receive weekly bathing as required.
A resident with multiple diagnoses received Digoxin without proper pulse monitoring, contrary to physician orders, and insulin pens were improperly labeled and primed. The Medication Aide and LPN failed to follow required procedures, as confirmed by the DON.
The facility failed to use recipes during meal preparation, affecting all residents who ate food prepared by the kitchen. Cook-A prepared a substituted soup without a visible recipe, relying on memory and making unauthorized ingredient changes. The DM confirmed that recipes must be approved by a remote RD, but no recipe was available at the time of observation.
The facility failed to maintain required food temperatures during meal service and did not remove foods stored beyond 7 days, affecting all 18 residents. The Certified Dietary Manager acknowledged the difficulty in maintaining appropriate temperatures and the need for more staff education. Additionally, the walk-in refrigerator contained items stored beyond the facility's policy limit.
The facility failed to store medications by route, administer eye drops correctly, and ensure accurate narcotic counts. An MA-C stored inhalation and topical medications with oral ones, administered eye drops incorrectly, and an LPN found a discrepancy in a controlled substance count.
The facility failed to document advanced directives and obtain physician signatures for two residents regarding their DNR status. This led to confusion and inappropriate medical interventions, including EMS performing CPR on a resident who was identified as DNR but lacked the necessary signed documentation.
The facility failed to honor a resident's preference for two baths per week, providing only one bath since admission. Despite the resident's care plan and documented preferences, the facility did not adhere to the requested bathing frequency, as confirmed by interviews with staff and the resident's spouse.
The facility failed to ensure routine bowel movements for a resident with severe cognitive impairment by not following the established Bowel Care Protocol. Despite the resident going multiple days without a bowel movement, required interventions were not documented or administered.
The facility failed to update or change fall prevention interventions for a resident with multiple falls, despite having a policy requiring care plan updates after each fall. The resident, with severe cognitive impairment and multiple diagnoses, continued to be at risk due to the lack of effective fall prevention measures.
The facility failed to ensure that medications used together for a resident did not lead to adverse consequences and that all medications had adequate indications for use with an appropriate diagnosis code. The resident was prescribed Trazodone and Buspirone, which can cause drowsiness and potentially lead to serotonin syndrome. Despite monthly reviews, there was no evidence of a review for reduction or discontinuation of these drugs. The resident did not have a diagnosis of major depressive disorder, which is a primary indication for Trazodone. Observations and interviews revealed the resident was frequently drowsy, had a significant decrease in food intake, and showed little interest in activities, suggesting the medications may have contributed to these issues.
Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to ensure that the code status for life-saving measures, including CPR, was accurately documented and consistently reflected for all residents, as required by policy and regulation. Specifically, for two residents, the electronic medical record (EMR), care plans, and physical indicators (such as door stickers and staff pocket care plans) did not match the residents' signed advance directives or physician orders. In one case, a resident who had a signed directive requesting full code status (CPR to be performed) was listed as Do Not Resuscitate (DNR) in the EMR and had a red dot on the door indicating DNR, while the daily staff pocket care plan listed the resident as full code. In another case, a resident who had a signed DNR order and advance directive was listed as full code in the EMR and on the staff pocket cheat sheet, contrary to the resident's wishes and physician's order. Interviews with staff revealed inconsistent knowledge and practices regarding how to verify and act on residents' code status. Medication aides and nurses relied on various sources, such as EMR, door stickers, and pocket care plans, but these sources were not always accurate or up to date. Some staff did not routinely check the code status before acting in an emergency, and there was confusion about which source was definitive. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that discrepancies existed between the signed code status documents and what was recorded in the EMR and other reference materials used by staff. The affected residents had significant medical histories, including conditions such as Parkinson's disease, diabetes, heart disease, and a history of heart attack. One resident was legally blind and had cognitive impairment, while the other had a history of cardiac issues and cancer. Both residents had clearly expressed their wishes regarding resuscitation, but the facility's failure to accurately document and communicate these wishes across all systems and to all staff created a situation where staff could have provided care that was contrary to the residents' directives.
Medication Error Rate Exceeds 5% Due to Late and Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a 37.04% error rate based on 27 opportunities with 10 errors. Errors included administering medications at the wrong time and omitting doses. For one resident with Parkinson's Disease, carbidopa/levodopa was scheduled for specific times but was administered late and not properly documented. Another resident had all morning medications scheduled for 6:00 AM, but these were administered late due to incorrect times in the electronic medication administration record (EMAR), which staff acknowledged had not been updated to reflect the facility's standard medication administration window. A third resident did not receive a scheduled dose of pantoprazole at the specified time because they had not yet come to the dining room for breakfast. Staff interviews confirmed awareness of the discrepancies between scheduled and actual administration times, as well as the inability to update the EMAR without pharmacy intervention. The Assistant Director of Nursing and the consulting pharmacist both acknowledged that the medications were given late according to the EMAR, and that the issue with incorrect times should have been addressed sooner. These actions and inactions led to multiple medication errors affecting at least three residents, in violation of the facility's medication error policy.
Failure to Perform Hand Hygiene Between Resident Contacts During Meal Assistance
Penalty
Summary
During a survey, it was observed that a Licensed Practical Nurse (LPN) failed to perform hand hygiene between assisting multiple residents during breakfast in the dining room. The LPN assisted one resident who frequently eats with their hands, then proceeded to assist several other residents, including helping with clothing protectors and touching residents' shoulders, without using alcohol-based hand sanitizer (ABHS) or washing hands between contacts. The LPN only used ABHS after assisting several residents and then continued to assist more residents before using ABHS again. A review of the facility's Hand Hygiene policy indicated that hand hygiene is required in all situations, especially when handling food or assisting residents, and that supplies are to be readily accessible. Interviews with the Assistant Director of Nursing (ADON) and the LPN confirmed that hand hygiene was not performed between resident contacts, and the LPN stated they did not have their usual personal bottle of ABHS that day. The deficiency had the potential to affect all nine sampled residents who were assisted during the meal.
Failure to Provide Required Medicare Beneficiary Notices Upon Discharge from Skilled Services
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to two residents who were discharged from Medicare Part A skilled services. For one resident, Medicare Part A skilled services began on 10/16/2024 and ended on 01/01/2025 due to a facility-initiated discharge. Although the resident remained in the facility and had additional benefit days available, the facility did not provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS-10055) to inform the resident that Medicare would no longer pay for their services. Staff explained that the resident did not indicate a desire to continue therapy at the time, but no documentation of the required notice was found. Similarly, another resident began Medicare Part A skilled services on 10/17/2024 and was discharged from these services on 11/20/2024, also through a facility-initiated process with benefit days remaining. The facility did not provide the SNF ABN, Form CMS-10055, nor the Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123), which is required to inform beneficiaries of their right to appeal the termination of Medicare coverage. Staff interviews confirmed that documentation for these notices could not be located, and the Assistant Administrator acknowledged that changes in social services had led to lapses in required documentation.
Failure to Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer was evaluated and monitored at least weekly, as required by both facility policy and regulatory standards. The resident in question had an unstageable pressure ulcer with eschar on the left heel that was present upon admission. The care plan specified that the location, size, and treatment of the skin injury should be monitored and documented, with weekly treatment documentation to include measurements and descriptions of the wound. Despite these requirements, multiple record reviews revealed a lack of documentation regarding the evaluation, measurement, or description of the left heel pressure ulcer. The electronic medical record, skin checks, total body skin assessments, progress notes, and medication administration records all failed to include the necessary details about the wound's size or condition. Observations confirmed the ongoing presence of the wound, but there was no evidence that staff had completed or recorded the required weekly assessments. Interviews with facility staff, including the DON, ADON, and an LPN, confirmed that the expected documentation was missing. The DON acknowledged that there was no documentation of evaluations or measurements for the resident's left heel wound, despite the facility's policy and the ongoing presence of the unhealed pressure ulcer.
Failure to Respond to Call Lights and Provide Routine Bathing
Penalty
Summary
The facility failed to respond to a resident's call light in a timely manner, as observed on multiple occasions. The resident, who was cognitively intact and had a history of multiple sclerosis, malnutrition, type 2 diabetes, neurogenic bladder, and enterocolitis due to clostridium difficile, was seen waiting in their wheelchair beside their bed with the call light activated. Despite the call light being on, the resident reported having to wait long periods for assistance, including a specific instance where the call light was activated for 23 minutes before being answered. The facility's Assistant Director of Nursing confirmed that there was no set standard for call light response times, but acknowledged that 23 minutes was longer than expected. Additionally, the facility did not ensure that the resident received routine bathing as per their preference and the facility's standard. The resident expressed a preference for bathing or showering twice a week upon admission, but records showed that they only received a bath or shower twice in a month-long period. The Director of Nursing confirmed that the facility's standard was for residents to receive a choice of bathing at least weekly, and acknowledged the lack of documentation indicating that the resident did not receive weekly bathing as outlined in the facility's Resident Handbook. These deficiencies highlight the facility's failure to provide timely assistance for activities of daily living and to adhere to their own standards for resident care. The resident's needs for assistance with bathing and timely response to call lights were not met, as evidenced by the observations and interviews conducted during the survey.
Medication Administration and Insulin Pen Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for Resident 1, who was admitted with diagnoses including hypertensive heart disease, type 2 diabetes, and atrial fibrillation. The resident's care plan required diabetic medication as ordered by the physician. During an observation, a Medication Aide (MA-B) administered Digoxin to the resident without obtaining an apical pulse as required by the physician's order. The MA-B used an electronic pulse oximeter and recorded a pulse of 59 beats per minute, which should have prompted the medication to be held and the provider notified, as per the order. However, the medication was administered, and the MA-B was unaware of the requirement to hold the medication for a pulse below 60 beats per minute. Additionally, the facility failed to ensure proper labeling and priming of an insulin pen for Resident 1. During an observation, an LPN used an insulin pen that was not labeled with the resident's identification, pharmacy label, expiration, or open date. The LPN confirmed that the insulin pens were not labeled correctly and should have been discarded. Furthermore, the LPN did not follow the manufacturer's recommendation or facility policy for priming the insulin pen, which required dialing two units and pressing the button to shoot insulin into the air. Instead, the LPN turned the dial randomly and depressed the plunger until insulin appeared. The Director of Nursing (DON) confirmed that the insulin pens should be properly labeled with the resident's information and open or discard date before use. The DON also confirmed that the LPN did not follow the correct procedure for priming the insulin pen. These deficiencies highlight the facility's failure to ensure that medications are administered according to physician orders and manufacturer guidelines, potentially compromising resident safety.
Failure to Use Recipes During Meal Preparation
Penalty
Summary
The facility failed to use recipes during meal preparation to ensure the nutritional adequacy of dishes served, affecting all residents who ate food prepared by the facility kitchen. During an observation, Cook-A was seen preparing a substituted soup of the day, Ham and Beans, without a visible recipe. The Certified Dietary Manager (DM) confirmed that recipes are generated from their Dining Manager computer program and must be approved by a remote Registered Dietician (RD). However, no recipe for the Ham and Beans soup was available at the time of observation, and the cook relied on memory to prepare the dish. Additionally, the weight and amount of diced ham were not measured, and the soup included ingredients not listed in the original recipe, such as carrots. Further interviews revealed that the facility uses a remote RD who visits every six months, with weekly remote calls. The DM stated that the facility is continually evolving due to frequent changes in resident census, requiring constant adjustments in the kitchen. The DM also mentioned that Cook-A is undergoing DM training. A record review indicated that the recipe for Ham and Bean soup served previously had unauthorized substitutions and additions, and the recipe had not been updated to reflect these changes. The DM confirmed that Cook-A did not follow a printed recipe, leading to the deficiency.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to ensure that foods were maintained at the required temperatures to prevent foodborne illnesses during meal service and did not remove and destroy foods that were in the refrigerator longer than 7 days. During an observation in the satellite kitchen of the LTC area, it was noted that the temperature of the turkey ham and cheese sandwich alternative was 135 degrees Fahrenheit, which is the minimum required temperature. However, by the end of the meal distribution, the temperature had dropped to 131 degrees Fahrenheit. The Certified Dietary Manager (DM) acknowledged the difficulty in maintaining the appropriate temperatures and indicated a need for more education on this matter. Additionally, during an inspection of the walk-in refrigerator, items such as sausage, mashed potatoes, and apples were found to be stored beyond the 7-day limit, contrary to the facility's policy of refrigerating leftovers for no longer than 3 days. The DM confirmed that the facility follows the leftover guidelines for food safety, but the observation revealed non-compliance. The DM also noted that some teaching had been done with the staff regarding maintaining temperatures and food storage. Despite this, the walk-in areas had not been cleaned or swept, indicating a lapse in maintaining cleanliness and proper food storage practices. These deficiencies had the potential to affect all 18 residents who consumed food from the facility kitchen.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to store medications administered by different routes separately for one resident. During a medication pass observation, a Medication Aide (MA-C) was seen retrieving both inhalation and topical medications from the same drawer as oral medications. The MA-C confirmed that these medications should be stored separately by route, as per the facility's policy. Additionally, the facility failed to administer eye drops following current professional standards of care for another resident. The MA-C incorrectly administered the eye drops by pulling up on the upper eyelid and placing the drop on the eyeball at the inner corner of the eye, instead of pulling down on the lower eyelid and instilling the drop close to the outer corner of the eye, as per the facility's policy on ophthalmic eye drop administration. The facility also failed to ensure accountability of a controlled substance for one resident. An LPN was observed preparing to administer a controlled substance liquid and found a discrepancy in the narcotic count. The LPN noted that the amount of medication in the bottle did not match the recorded amount in the narcotic record book. The Director of Nursing (DON) confirmed the discrepancy, noting that the amount of medication in the bottle was less than what was documented. The facility's policy requires accurate documentation and verification of controlled substances, which was not adhered to in this instance.
Failure to Document Advanced Directives and Obtain Physician Signatures
Penalty
Summary
The facility failed to obtain and document the advanced directives for two residents regarding their code status. For Resident 61, the facility did not have a completed Advanced Directives form or a signed Physician's Do Not Resuscitate (DNR) Order. This led to confusion when Resident 61 was found unresponsive and not breathing. Despite the nurse identifying the resident as DNR, Emergency Medical Services (EMS) initiated CPR due to the absence of a signed DNR form, and Resident 61 was transported to the hospital where they later died. Interviews with the Social Services Director, Assistant Administrator, and Director of Nursing confirmed the absence of the necessary documentation for Resident 61's DNR status. For Resident 68, the facility had a Physician's Do Not Resuscitate (DNR) Order form signed by the resident but lacked the physician's signature. Despite having an active physician order for DNR in the medical records, the absence of the physician's signature on the DNR form meant that the resident's wishes were not fully documented. The Director of Nursing confirmed the missing physician signature during an interview. These deficiencies highlight the facility's failure to properly document and honor residents' advanced directives, specifically regarding their code status. The lack of signed physician orders for DNR in both cases resulted in potential miscommunication and inappropriate medical interventions, as evidenced by the events involving Resident 61 and Resident 68.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of Resident 71, who was admitted on 05/01/2024. Resident 71, with a BIMS score of 10 indicating mild cognitive impairment, expressed a preference for two baths per week, which was confirmed by both the resident and their spouse during an interview. However, a review of the resident's bathing task report and progress notes revealed that only one bath was documented since admission, with no records of refusals or additional baths provided. The resident's care plan also indicated a need for two baths per week, but this was not adhered to by the facility staff. Interviews with the Bath Aide and the Director of Nursing revealed that the facility's process for documenting and following resident preferences was not effectively implemented. The Bath Aide confirmed that Resident 71 had only received one bath since admission, and the Director of Nursing acknowledged that preferences are documented on a personal preference sheet and a bathing schedule, but there was no policy in place to ensure these preferences were consistently followed. The lack of proper documentation and adherence to the resident's care plan led to the failure in providing the requested bathing frequency for Resident 71.
Failure to Follow Bowel Care Protocol
Penalty
Summary
The facility failed to ensure routine bowel movements for Resident 2, who had severe cognitive impairment and required substantial assistance with daily activities. Despite having a Bowel Care Protocol in place, the facility did not follow the protocol for Resident 2, who went multiple days without a bowel movement on several occasions in April 2024. The protocol required specific interventions after three days without a bowel movement, but these interventions were not documented or administered for Resident 2. Interviews with the Registered Nurse and the Director of Nursing confirmed that the facility's bowel protocol was not followed. The night shift was responsible for creating a list of residents who had not had a bowel movement in three days, and the day shift was supposed to administer the necessary interventions. However, Resident 2 was listed as not having a bowel movement for five days, and no interventions were documented in the medication administration record or progress notes for the entire month of April 2024.
Failure to Update Fall Prevention Interventions
Penalty
Summary
The facility failed to update or change interventions to prevent falls for one resident, identified as Resident 2, who had multiple falls. Resident 2, admitted with diagnoses including dementia, mood disturbance, anxiety, type 2 diabetes, muscle weakness, and pain, had a severe cognitive impairment and required substantial assistance with daily activities. Despite having documented falls on 12/11/2023, 01/27/2024, 02/17/2024, and 02/26/2024, the facility did not update the resident's care plan with new or changed interventions to prevent further falls. Observations on 04/29/2024 and 04/30/2024 showed Resident 2 in precarious positions in bed, indicating a lack of effective fall prevention measures. Interviews with staff, including a Medication Aide, Registered Nurse, MDS Coordinator, and Director of Nursing, confirmed that fall prevention interventions were not adequately updated on the care plan after each fall. The facility's policy required the care plan to be reviewed and updated after each fall, but this was not done for Resident 2. The Post-Fall Checklist dated 02/12/2023 also indicated that the care plan should be updated with new interventions and goals after a fall. Despite these requirements, the care plan for Resident 2 did not reflect new or changed interventions after the falls, and the interventions documented were already present on the care plan. This failure to update the care plan with new interventions after each fall contributed to the continued risk of falls for Resident 2.
Failure to Ensure Safe Medication Use and Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that medications used together for Resident 3 did not lead to adverse consequences and that all medications had adequate indications for use with an appropriate diagnosis code. Resident 3 was prescribed Trazodone and Buspirone, both of which can cause drowsiness and have the potential to lead to serotonin syndrome when used together. Despite being reviewed monthly for gradual dose reductions, there was no evidence that these two drugs were reviewed for reduction or discontinuation. Additionally, Resident 3 did not have a diagnosis of major depressive disorder, which is a primary indication for Trazodone use, as per the order summary and Minimum Data Set (MDS) records. The resident's diagnosis was listed as dementia with mood disturbances, insomnia, restlessness, and agitation, but not major depressive disorder. This discrepancy indicates a lack of appropriate diagnosis for the prescribed medication. Observations and interviews revealed that Resident 3 was frequently drowsy, slept a lot, and had a significant decrease in food intake, leading to weight loss. The resident's spouse confirmed that Resident 3 had stopped eating and required assistance with drinking water. The resident was observed to be sleeping frequently, both in bed and in a wheelchair, and showed little interest in activities. These observations suggest that the medications may have contributed to the resident's lethargy and decreased appetite, further highlighting the need for a thorough review of the drug regimen. The facility's failure to review and adjust the medications appropriately for Resident 3, considering the potential adverse interactions and the lack of a proper diagnosis for Trazodone, led to the deficiency noted in the report.
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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 Grand Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Nursing & Rehab Lakeview | 1.6 mi | ★★★★★ | 19 | 1 |
| Tiffany Square | 2.6 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Grand Island Village | 2.8 mi | ★★★★★ | 16 | 0 |
| Chi Health St. Francis | 2.8 mi | ★★★★★ | 0 | 0 |
| Adept Nursing & Rehab Of Grand Island | 2.9 mi | ★★★★★ | 0 | 0 |
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