Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Williamsburg during CMS and state inspections, most recent first.
A resident admitted with multiple fractures and post-surgical pain had a Buprenorphine transdermal patch ordered weekly, with instructions to remove the old patch and rotate sites. Medication records showed the patch was applied on two consecutive weeks, and an incident report later revealed MAs failed to remove the old patch on two subsequent application dates, leaving multiple patches in place. Although the facility’s policy required narcotic patches to be checked three times daily and the DON expected staff to remove the old patch before applying a new one, there was no system in place at the time to ensure this occurred.
Infection control standards were not followed during wound care for a resident with cellulitis and a daily dressing change order. An RN used the same gloves while handling room surfaces, supplies, clothing, a bag, and scissors, placed wound care items directly on an unclean overbed table, washed hands for only 12 seconds, and did not change gloves between dirty and clean tasks. The RN confirmed the table was not clean and that hand hygiene and glove changes should have occurred between multiple steps of the dressing change.
A resident's representative was not informed about a large, painful bruise of unknown origin or the denial of hospice admission. Documentation and interviews revealed that staff did not complete required assessments, incident reports, or timely notifications to the family, resulting in a deficiency related to communication and documentation of significant changes in the resident's condition.
A resident developed a large, painful bruise of unknown origin that was first noticed by a Medication Aide and later observed to have increased in size. Despite facility policy requiring reporting and investigation of such injuries, the DON did not initiate an incident report or investigation, citing the resident's history of frequent bruising. The required report and investigation were not completed or submitted to the State Agency within the mandated timeframe.
A resident with severe cognitive impairment developed a large, painful bruise of unknown origin that was not promptly reported or investigated by staff. The DON was aware of the injury but did not initiate an incident report or investigation, contrary to facility policy requiring such action for injuries of unknown or suspicious origin.
The facility failed to properly store food and ensure hair was fully contained under hairnets during meal service, risking foodborne illness for 30 residents. Observations showed improperly labeled and expired food items, and an LPN was seen with an exposed ponytail, contrary to the Nebraska Food Code.
A resident with moderate cognitive impairment and an indwelling foley catheter did not receive proper hand hygiene during catheter care. A Nursing Assistant changed gloves without performing hand hygiene, contrary to facility policy and CDC recommendations. Interviews confirmed the requirement for hand hygiene when changing gloves.
Failure to Remove Prior Narcotic Patch Before Applying New Dose
Penalty
Summary
Surveyors identified a failure to follow professional standards of practice in the administration of a transdermal narcotic patch for one resident. The resident was admitted after a fall that caused fractures of the right upper arm, sacrum, and right pubis, and had undergone surgery to repair the right upper arm fracture. During the hospital stay, an order for a Buprenorphine transdermal patch was initiated, and upon admission the facility’s order summary directed staff to apply a 7.5 mcg/hr Buprenorphine patch every seven days on Fridays, remove the old patch, and rotate the site. Medication administration records showed that the patch was applied on two consecutive Fridays. The facility’s incident report later documented that medication aides did not remove the old Buprenorphine patch on two subsequent Fridays, resulting in more than one patch remaining on the resident’s skin. Progress notes indicated that the resident and family requested the patch be held due to minimal pain, and the medication administration record showed the patch was held and not administered on the specified March dates. The DON stated that, prior to the incident being brought to their attention, the facility did not have a system in place to ensure removal of the old patch before applying a new one, despite a written policy requiring all narcotic patches to be checked for placement three times daily and the expectation that MAs/nurses remove the old patch before placing a new one.
Infection Control Failure During Wound Care
Penalty
Summary
Infection control standards of practice were not followed during wound care for a resident with cellulitis of the left arm who had a current order for a daily dressing change to the wound. During the wound care observation, the RN entered the room, used hand sanitizer, put on gloves, and retrieved supplies from a cupboard, then placed the supplies directly on the overbed table without a barrier. The RN pushed the resident’s sleeve up, opened the Vashe cleanser, applied it to gauze, and wiped the wound while wearing the same gloves, then left the gauze on the wound. The RN later measured the wound and replaced the gauze, still wearing the same gloves. The RN then handled clothing, walked into the hall and nurse’s station, reached into a black bag, and retrieved scissors from a scrub pocket before removing gloves and washing hands for 12 seconds. After returning to the room and putting on gloves again, the RN cleaned the scissors with an alcohol wipe, used them to cut Vaseline gauze, removed the Vashe gauze from the wound, and applied the new dressing. The RN then dated and initialed the dressing while wearing the same gloves, placed supplies away, and locked the cupboard. The RN confirmed the overbed table had not been clean, that a barrier should have been used, and that hand hygiene and glove changes should have occurred between touching objects such as the cupboard door, keys, clothing, or a bag and touching the resident or wound care supplies, and between removing the old dressing, cleaning the wound, and applying the new dressing. The Administrator confirmed the facility did not have a policy for wound care.
Failure to Notify Family of Significant Change and Hospice Denial
Penalty
Summary
The facility failed to notify a resident's representative of two significant events: the denial of hospice admission and the discovery of a large, painful bruise of unknown origin. Documentation shows that a medication aide first noticed the bruise on the resident's left side, radiating into the waist area and under the left breast, but it was not documented in the progress notes until several days later. The bruise increased in size and became painful, yet there was no record of a fall, no SBAR was completed, and the APRN was not asked to assess the bruise during a facility visit. Additionally, there was no skin assessment documented for the bruise prior to its entry in the progress notes, and the RN did not complete an incident report as required. Interviews confirmed that the resident's representative was not informed about the bruise or the denial of hospice admission. The representative, who visits the facility multiple times daily, only learned of the hospice denial after contacting hospice directly. Social Services and the DON both assumed that either hospice or another party would notify the family, but no such communication occurred. The lack of documentation and communication regarding these significant changes in the resident's condition and care status led to the identified deficiency.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and submit a completed investigation of an injury of unknown origin for one resident to the State Agency within the required five working days. According to the facility's own policy, any injury of unknown or suspicious origin, including bruises that are not easily explained, must be reported and investigated. In this case, a large, bruised area was first noticed by a Medication Aide on the resident's left side, radiating into the waist area and under the left breast. The bruise increased in size and became painful, yet there was no documentation of a fall or incident that could explain the injury. The resident had a chair alarm in place and was variably assisted with ambulation and transfers, but no SBAR was completed, and the Advanced Practice Registered Nurse was not asked to assess the bruise when present in the facility. Interviews revealed that the Director of Nursing became aware of the bruise after it was reported several days later but did not initiate an incident report or investigation. The DON stated that the resident frequently gets bruises and did not feel it was necessary to report or investigate this particular bruise. As a result, the required incident report and investigation were not completed or submitted to the State Agency within the mandated timeframe, constituting a failure to comply with both facility policy and state regulations.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an incident of injury of unknown origin for one resident. The resident, who had a diagnosis of dementia and neurocognitive disorder with severely impaired cognitive function, was observed to have a large, dark purple/red bruise on the left hip extending up the side. The bruise was first noticed by a medication aide, but was not reported until several days later, by which time it had increased in size and the resident was experiencing pain. There was no documentation of any falls, and the resident had a chair alarm in place. No SBAR was completed, and the APRN was not asked to assess the bruise during a facility visit. Interviews with staff confirmed that the Director of Nursing (DON) was aware of the bruise after it was reported but did not initiate an incident report or conduct an investigation. The DON stated that the resident frequently gets bruises and did not see the need to report or investigate this particular incident. This lack of action was in direct contradiction to the facility's policy, which requires that all injuries of unknown or suspicious origin be reported and investigated.
Deficiencies in Food Storage and Hair Restraint Compliance
Penalty
Summary
The facility failed to adhere to its own policies regarding food storage and handling, which could potentially lead to foodborne illnesses among the 30 residents. Observations revealed that food items in the Harbor House refrigerator were not labeled with expiration dates, and some items had been stored beyond the three-day limit specified in the facility's policy. Specifically, a meat and cheese tray and a plate of mixed cheese were found without expiration dates, and an opened bag of sliced turkey was stored beyond the allowed period. The Chef Manager confirmed that these items should have been removed after three days, as per the facility's policy. Additionally, the facility did not comply with the Nebraska Food Code regarding hair restraints during food service. An LPN was observed wearing a hairnet that did not fully contain their hair, leaving a ponytail exposed. Interviews with the LPN, the Director of Nursing, and the Certified Dietician confirmed that all hair should be contained under a hairnet, although the facility lacked a specific hairnet policy and relied on the Nebraska Food Code for guidance.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during catheter care for a resident, identified as Resident 18, who had an indwelling foley catheter. The facility's policy, last reviewed on 10/26/24, recommended the use of alcohol-based hand rub in all situations except when hands are visibly soiled. Additionally, the CDC recommends washing hands before and after using gloves to prevent the spread of germs. During an observation on 11/20/24, a Nursing Assistant (NA) was seen changing gloves without performing any hand hygiene, and there was no hand sanitizer within reach. Resident 18 had been admitted to the facility with a Minimum Data Set (MDS) indicating moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 11. The resident's Comprehensive Care Plan (CCP) included instructions for catheter care per physician orders initiated on 11/1/24. In interviews following the observation, both the NA and a Licensed Practical Nurse (LPN) confirmed that hand hygiene is required when changing gloves, highlighting a lapse in adherence to infection prevention protocols.
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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 Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartland Ridge Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 1.6 mi | ★★★★★ | 27 | 0 |
| Ambassador Health Of Lincoln | 2.7 mi | ★★★★★ | 3 | 0 |
| St. Jane De Chantal | 2.9 mi | ★★★★★ | 27 | 0 |
| Holmes Lake Rehabilitation & Care Center | 3 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.