Eventide Lincoln Care Center: Call Light Failures - NE
Federal inspectors documented twenty separate incidents between December 1 and December 28 in which call lights at the facility went unanswered within the time the facility's own staff said was required. Twenty times across twenty-eight days, spread across early mornings, middays, afternoons, and at least once past midnight. The pattern ran through the holiday stretch, including Christmas Day and the days surrounding it.
The incidents ranged from under thirty minutes of observation to just over an hour. On December 19, inspectors were present at 12:46 in the morning. On December 26, they documented three separate incidents in a single day, at 8:58 AM, 11:37 AM, and again at 2:06 PM. The problem was not occasional. It was structural.
What makes the findings harder to dismiss is what facility leadership said when inspectors asked about it.
On December 30, a registered nurse identified in the report as RN D confirmed to inspectors that the expectation at Eventide Lincoln was that call lights would be answered within five minutes. Later that same evening, the facility's Executive Director confirmed the same standard. Five minutes. Their own policy, last revised in August 2024, said staff should respond to call lights in a timely manner. Five minutes was how the facility defined timely.
Both the nurse and the executive director confirmed the rule. Neither disputed that it existed. The inspection report does not record either of them offering an explanation for why it was not being followed across twenty documented instances in a single month.
Call lights are how nursing home residents ask for help. A resident who cannot get out of bed without assistance uses a call light to ask someone to help them to the bathroom. A resident in pain uses one to ask for medication. A resident who has fallen, or is about to fall, uses one to ask for someone to come. When the light goes unanswered, the resident waits, or tries to manage alone, or gives up asking.
The inspection was triggered by a complaint. Inspectors were on site on multiple dates, which accounts for how the twenty incidents were captured across the month rather than in a single visit. The level of harm was classified as minimal harm or potential for actual harm, affecting a small number of residents.
That classification reflects the regulatory framework inspectors work within. It does not mean nothing happened to the people who pressed those buttons and waited. The report does not describe what any specific resident needed when they activated their call light, or how long they waited, or what they did when no one came. Those details are not in the record.
What is in the record is the timeline. December 1, December 2, December 3, December 4, December 5. Then December 6, twice. December 7, twice. December 9, twice. December 12. December 19, just before 1 in the morning. December 20. December 23, twice. December 26, three times. December 28, just after 6 in the morning.
The facility's executive director, asked about it on December 30, confirmed the five-minute standard was the expectation. The inspection report ends there, with the standard confirmed and the violations documented and the month already over.
The residents who pressed those lights in the dark on December 19, or on Christmas morning, or on any of the other eighteen occasions inspectors recorded, had already done their waiting by then.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eventide Lincoln Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Eventide Lincoln Care Center in Lincoln, NE was cited for violations during a health inspection on December 31, 2025.
Twenty times across twenty-eight days, spread across early mornings, middays, afternoons, and at least once past midnight.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.