Eventide Prairie Commons Care Center

In the surveyor’s words

From the most serious findings on record at Eventide Prairie Commons Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 1, 2025

  Based on record reviews and interviews, the facility failed to ensure resident code status for life saving measures were accurate for all residents. This affected 2 (Resident 1 and Resident 18) of 23 sampled residents. The facility census was 23. [NAME] at Prairie Commons was notified on [DATE] at 1:43 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] at 5:20 PM, as confirmed by surveyor onsite verification. Findings are: Record review of the facility policy Advanced Directives dated [DATE] stated the purpose of the policy was to recognize the Senior's rights to make decisions relating to their own medical care, including the right to accept or refuse treatment and the right to formulate an advanced directive (a document allowing a person to give… […]

• Actual harm, isolatedF689Jun 3, 2026

  Licensure Reference Number 175 NAC 12-006.09(I)Licensure Reference Number 175 NAC 12-006.09(I)(i)(1)Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)Based on observation, record review, and interview the facility failed to provide and implement interventions to protect residents from sunburn injury for 1of 3 residents (Resident 1). This caused Resident 1 to experience sunburn injury requiring treatment. The facility census was 27.Findings are:Record review of the undated facility Elder Abuse Prevention Program revealed that the facility will not tolerate any form of elder abuse. Neglect is a failure of the facility, its employees, or service providers to provide goods and services to an elder necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• No harm, potential for more than minimal, widespreadF803May 1, 2024

  Licensure Reference Number 175 NAC 12-006.11A1 Based on record review, observation and interviews; the facility failed to use recipes during meal preparation of all foods to ensure the nutritional adequacy of dishes served. This affected all residents that ate food prepared by the facility kitchen. Current census was 18. Findings are: Observation on 04/30/24 at 9:21 AM in the facility's main kitchen. Observed the Cook-A (C-A) preparing a substituted soup of the day; Ham and Beans. There was no recipe visible. This will be an alternative to scheduled soup of the day. Information was sent out to the satellite areas so that all residents were aware of the change. Interview on 04/30/24 at 9:25 AM with the Certified Dietary Manager (DM). […]

• No harm, potential for more than minimal, widespreadF812May 1, 2024

  Licensure Reference Number 175 NAC 12-006.11E Based on record review, observation and interviews; the facility failed to ensure that foods were maintained at the required temperatures to prevent food borne illnesses on the steam table during meal service and failed to remove and destroy foods that were in the refrigerator longer than 7 days. This had the ability to affect all 18 residents who ate food served by the facility kitchen. Current census was 18. Findings are: A. The Nebraska Food Code of 2017 states that foods must be heated to a temperature of 165 degrees Fahrenheit prior to serving and can then be held for hot holding at a temperature of 135 degrees Fahrenheit until served for up to two hours. […]

• No harm, potential for more than minimal, patternF759May 1, 2025

  Licensure Reference Number 175 NA 12-006.10(D) Based on record reviews, observations and interviews, the facility failed to ensure medication error rates were not 5% or greater (27 opportunities with 10 errors resulted in an error rate of 37.04%). This affected 3 (Residents 1, 5, and 123) of 4 residents sampled. The facility census was 23. Findings are: Record review of the undated Medication Error Policy revealed it is the facility policy to ensure residents are free from significant medication errors and that the facility maintains a medication error less that 5%. Medication errors included the following errors: Wrong time Omission of a medication Record review of the undated facility medication times revealed that 6:00 AM to 11:00 AM [NAME] is called AM 6a-11a. […]