Cycle 1
Health 2025-05-01 · Fire 2025-05-01
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Grand Island, NE
Tabitha At Prairie Commons
2-star overall rating with 1-star inspections with $10,296 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3490 Ewoldt Street, Grand Island, NE
(308) 321-1122
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
20
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2023-04-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.98
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.91
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.10
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
5.99
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
2.89
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
5.30
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
5.89
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,681
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.13
Performance 20.45% · Measure score 2.13 · Achievement 2.13 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.66
Performance 6.14% · Measure score 5.66 · Achievement 5.66 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.06% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 12.5% · Lower 95% interval 7.23% |
| Discharge to community | 62.17% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 71 · Observed rate 64.79% · Lower 95% interval 51.79% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 27.78% |
95.27%
67.5 pts worse
|
Numerator 25 · Denominator 90 |
| Falls with major injury | 1.11% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 90 |
| Discharge self-care score | 58.57% |
53.69%
4.9 pts better
|
Numerator 41 · Denominator 70 |
| Discharge mobility score | 54.29% |
50.94%
3.4 pts better
|
Numerator 38 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 3 · Denominator 90 · Adjusted rate 3.18% |
| Healthcare-associated infections requiring hospitalization | 6.14% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 1.69% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 1.59% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 126 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 62.86% |
56.45%
6.4 pts better
|
Numerator 44 · Denominator 70 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 42 · Denominator 42 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 13.56% |
25.2%
11.6 pts worse
|
Numerator 8 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
92.8%
5 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.5%
4.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.8% |
4.4%
8.4 pts worse
|
11.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.8% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.3%
5.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
19.5%
1.6 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
21.6%
6.8 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
19.9%
2.8 pts better
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 9.0% |
1.6%
7.4 pts worse
|
1.0%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.8% |
2.9%
3.9 pts worse
|
1.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 41.6% |
26.6%
15 pts worse
|
19.8%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 41.6% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
4.3%
3.4 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.9% |
80.5%
0.4 pts better
|
81.7%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.1% · Q2 72.7% · Q3 78.3% · Q4 89.6% · 4Q avg 80.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
11.6%
6.2 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.4%
1.3 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
75.9%
8.9 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.7% |
20.9%
9.2 pts better
|
23.9%
12.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 10.0% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-04-12 · Fire 2023-04-12
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-05-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-05-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-05-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-05-01
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-05-01
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-06-03
Inspection history
Recent health citations
J · Immediate jeopardy
2025-05-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-05-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-05-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-05-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-27
D · Potential for more than minimal harm
2024-12-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-06
D · Potential for more than minimal harm
2024-12-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-06
F · Potential for more than minimal harm
2024-05-01
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-05-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-05-01
E · Potential for more than minimal harm
2024-05-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-05-01
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-05-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-01
Penalties and ownership
What sits behind the stars
$10,296
2025-05-01
Fine
Fine · fine $10,296
Fine
Ownership
Eventide Nebraska Senior Living LLC
5% Or Greater Indirect Ownership Interest · Organization
Tabitha, Inc.
5% Or Greater Direct Ownership Interest · Organization
Acton, Sherrill
W-2 Managing Employee · Individual
Bock, Jodee
Corporate Director · Individual
Brandt, Terry
Corporate Director · Individual
Bye, Robert
Corporate Director · Individual
Bye, Robert
Corporate Officer · Individual
Crouch, Ryan
Contracted Managing Employee · Individual
Eventide
Operational/Managerial Control · Organization
Fischbach, Tyler
Corporate Director · Individual
Gulbranson, Patrick
Corporate Director · Individual
Halvorson, Joseph
Corporate Director · Individual
Hvidston, Luke
Corporate Director · Individual
Hvidston, Luke
Corporate Officer · Individual
Johnson, Vikki
Corporate Director · Individual
Johnson, Vikki
Corporate Officer · Individual
Larson-Casselton, Cindy
Corporate Director · Individual
Lee, Judith
Corporate Director · Individual
Lunak, Brandon
Corporate Director · Individual
Ohe, Darin
Operational/Managerial Control · Individual
Riewer, Jon
Corporate Officer · Individual
Schafer, Eric
Corporate Director · Individual
Seljevold, Peter
Corporate Director · Individual
Swenson, Karla
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Emerald Nursing & Rehab Lakeview
Grand Island, NE
2-star overall rating with 3-star inspections with $13,000 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Tiffany Square
Grand Island, NE
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Grand Island Village
Grand Island, NE
1-star overall rating with 2-star inspections with $10,033 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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