Eventide Prairie Commons Care Center
3490 Ewoldt Street, Grand Island, NE 68803 · Hall County · 36 certified beds · avg 31 residents/day · certified since Apr 12, 2023
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · May 1, 2025 · F-0678
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 27, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 3, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 25, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 3, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 1, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| May 1, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 1, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Dec 23, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Dec 23, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 1, 2024 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| May 1, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 1, 2024 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| May 1, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 10 | 0 | F |
| 2025 | 5 | 1 | J ▲ |
| 2026 | 1 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $10,296.
| Date | Type | Amount / length |
|---|---|---|
| May 1, 2025 | Fine | $10,296 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.46 | 4.33 | 3.95 | top 41% in Nebraska; top 24% in the U.S. |
| Registered Nurse hours | 0.87 | 0.72 | 0.69 | top 29% in Nebraska; top 23% in the U.S. |
| Weekend total nurse staffing | 4.22 | 3.79 | 3.50 | top 27% in Nebraska; top 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.81 | 0.47 | 0.48 | top 9% in Nebraska; top 11% in the U.S. |
| Total nursing staff turnover (%) | 67.4 | 48.7 | 45.8 | bottom 13% in Nebraska; bottom 8% in the U.S. |
| RN turnover (%) | 85.7 | 44.1 | 42.9 | bottom 6% in Nebraska; bottom 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.41, RN 0.86, weekend 4.17. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Eventide Nebraska Senior Living LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 10/10/2024 |
| Tabitha, INC. | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/22/2022 |
| Acton, Sherrill | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/22/2024 |
| Bock, Jodee | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Brandt, Terry | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Bye, Robert | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Bye, Robert | Individual | Corporate Officer | NOT APPLICABLE | 10/10/2024 |
| Eventide | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/19/2024 |
| Fischbach, Tyler | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Gulbranson, Patrick | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Hervert, Mitchell | Individual | ADP of the SNF | NOT APPLICABLE | 04/10/2026 |
| Johnson, Vikki | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Johnson, Vikki | Individual | Corporate Officer | NOT APPLICABLE | 10/10/2024 |
| Larson-Casselton, Cindy | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Lee, Judith | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Lunak, Brandon | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
| Lunak, Brandon | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2026 |
| Ohe, Darin | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/22/2024 |
| Riewer, Jon | Individual | Corporate Officer | NOT APPLICABLE | 10/10/2024 |
| Schafer, Eric | Individual | Corporate Director | NOT APPLICABLE | 10/10/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Emerald Nursing & Rehab Lakeview | 1.6 mi | Grand Island, NE | ★☆☆☆☆ | 1/5 | |
| Tiffany Square | 2.6 mi | Grand Island, NE | ★★☆☆☆ | 3/5 | |
| Good Samaritan Society - Grand Island Village | 2.8 mi | Grand Island, NE | ★☆☆☆☆ | 2/5 | |
| Chi Health St. Francis | 2.8 mi | Grand Island, NE | ★★★☆☆ | 4/5 | |
| Adept Nursing & Rehab of Grand Island | 2.9 mi | Grand Island, NE | ★☆☆☆☆ | 1/5 | |
| Westfield Quality Care of Aurora | 19.2 mi | Aurora, NE | ★☆☆☆☆ | 1/5 | |
| Memorial Community Care | 19.5 mi | Aurora, NE | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 285307.