Eventide Lutheran Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an incident of neglect of care with serious bodily injury was reported within 2 hours of the State Agency (SA) for 1 of 1 residents (R1) who fell out of bed and sustained a fractured clavicle along with a laceration when staff were not following the care plan.Findings include:R1's annual minimum data set (MDS) dated [DATE], identified R1 was cognitively intact. and was dependent on staff for toileting, bed mobility, and transferring. R1 had anxiety, pain and a history of falls with fractures.R1's care plan revised 6/13/26, identified R1 had a potential for falls related to decreased mobility, a history of falls, and weakness. R1 was alert and orientated to person, place and time. R1's care planned interventions included low bed with fall mat to the floor when R1 was in bed and soft touch call light at the hip to promote use.R1's fall risk predictive factors assessment dated [DATE], indicated R1 had poor recall, judgment, and safety awareness.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review, the facility failed to ensure orders were followed as prescribed by the physician for 1 of 3 residents (R1) reviewed for post-op care after a right great toe amputation. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified severely impaired cognition with physical behavioral symptoms towards others (hitting, kicking, pushing, scratching, grabbing) and verbal behavioral symptoms directed towards others (screaming, threatening others and cursing). Medical diagnoses included: non-traumatic brain dysfunction, peripheral vascular disease (PVD) (a circulation disorder where blood vessels outside the heart become narrowed, blocked, and can cause pain, cramping, numbness, and poor wound healing), diabetes mellitus (DM), and Alzheimer's. R1's care plan dated 11/12/25, identified a potential for skin breakdown related to dementia, urinary incontinence, history of stage 2 pressure ulcer to right buttock and seborrheic dermatitis, right great toe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 1 of 1 residents (R4) who received assistance with eating in the dining room. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had severe cognitive impairment and had diagnoses which included: hypertension (elevated blood pressure), dementia, and anemia. Identified R4 required staff assistance to eat. R4's care plan dated 11/9/22, identified R4 had self-care performance deficit related to weakness and dementia. R4's interventions included assistance with hygiene, bathing and dressing. Identified R4 required total staff assistance with eating. Identified R4 had a terminal prognosis and received hospice care. During an observation on 6/24/25 at 12:35 p.m., R4 sat in a reclining wheelchair in the dining room at a table. Hospice registered nurse (H-RN) stood near R4's right side, and provided R4 with food from a spoon. -at 12:43 H-RN continued to stand near R4's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 residents (R5) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnoses which included pneumonia, hip fracture, and respiratory failure. R5 was dependent on staff for transfers and toileting hygiene. R5's care plan dated 5/30/25, identified R5 as having an activity of daily living (ADL) self-care performance deficit related to a fracture of the right ankle. R5's care plan interventions included assistance with dressing and grooming and being able to feed self after staff assisted with tray set up. Review of the care plan dated 5/30/25, lacked information regarding the self-administration of medications. Review of R5' s electronic health record (EHR) revealed Formoterol Fumarate inhalation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R95) had adequate hydration within reach. Findings include: R95's quarterly Minimum Data Set (MDS) dated [DATE], indicated R95 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. R95 required partial assistance with eating and extensive assistance with dressing and personal hygiene. R95 had a diagnosis of cerebral infection (stroke), hemiparesis (weakness of one side of the body), anxiety, and depression. R95's care plan was revised on 3/12/25, indicating that R95 could feed herself after staff assisted with tray setup. Staff to encourage R95 to use her right hand to feed herself, and place the tray in the far-right visual felid. Dysphasia mechanically altered with nectar thick liquids, on 4/3/25 per speech therapy changed to pureed with nectar thick liquids with hopes of improving intakes. Dislikes strawberries. The family prefers that R95 be given cranberry juice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to honor a resident's right to make choices about food choices at meals for 1 of 1 residents (R95) reviewed for choices. Findings include: R95's quarterly Minimum Data Set (MDS) dated [DATE], indicated R95 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. R95 required partial assistance with eating and extensive assistance with dressing and personal hygiene. R95 had diagnoses of cerebral infection (stroke), hemiparesis (weakness of one side of the body), anxiety, and depression. R95's care plan revised on 3/12/25, indicated R95 could feed herself after staff assisted with tray setup. Staff to encourage R95 to use her right hand to feed herself and place the tray in the far-right visual felid. R95's diet was changed on 4/3/25, per speech therapy to pureed (smooth blended foods) with nectar thick liquids with hopes of improving intakes. The family preferred that R95 be given cranberry juice to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process, following the initiation of hospice services for 1 of 1 resident (R117) reviewed for hospice. Findings include: R117's quarterly Minimum Data Set (MDS) dated [DATE], identified R117 had severe cognitive impairment and diagnoses which included Alzheimer's disease, dementia, and traumatic brain injury. Identified R117 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R117's progress notes dated 3/31/25 to 5/19/25, identified R117 was admitted to Ethos Hospice on 4/28/25. R117's electronic medical record (EMR) identified a quarterly MDS was completed on 2/28/25, and a death MDS was completed on 5/19/25. R117 EMR lacked a significant changed MDS was completed when R117 was admitted to hospice. During an interview on 6/25/25 at 11:11 a.m., MDS coordinator confirmed R117…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a pressure relieving device was implemented to prevent skin breakdown for 1 of 3 residents (R22) reviewed for pressure ulcers. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had severe cognitive impairment and diagnoses which included hemiplegia (paralysis on one side of the body), aphasia (disorder that affects the ability to communicate), and Parkinson's Disease. Identified R22 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R22 was at risk for pressure ulcers. R22's annual Care Area Assessment (CAA) dated 10/19/24, identified R22 required total assistance from staff with repositioning and was at risk for skin breakdown. Identified R22 was incontinent of bowel and bladder. R22's care plan dated 10/14/2016, identified R22 had self care deficits and was at risk for skin breakdown related to stroke and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure appropriate hand hygiene and personal protective equipment (PPE) practices were performed during a high contact care activity for 2 of 3 residents (R1, R5) in enhanced barrier precautions (EBP) with an indwelling device. Findings include: Primary provider visit dated 2/4/25 at 8:00 p.m. identified assessment/plan: neurogenic bladder - continue with suprapubic catheter (a flexible tube placed through an incision in the abdomen instead of from the urethra to empty urine from the bladder into a collection bag) (SP), Mirabegron 25 milligrams (mg) (medication for bladder spasms). Nursing was responsible for catheter cares. No recent urinary tract infection (UTI) concerns. R1's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition without behaviors. She had upper impairment on one side, lower impairment on both sides and used a wheelchair for mobility. She required partial/moderate assistance with upper body dressing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. This deficient practice had the potential to affect all 116 residents who received food and beverages from the refrigerators and freezers. Findings include : On 4/8/24 at 11:30 a.m., during the initial tour of the kitchen area with the culinary coordinator (CC), the following concerns were identified: Walk in produce cooler: -nine hard boiled eggs were in a Ziploc bag without a notation of a date. -1/2 large container of enchilada sauce with crusty black flakes around the lid with an open date of 1/1/24. -1/2 bottle of mustard with yellow crusty flakes around the lid and an open date of 10/3/23. -1/4 bag of whipped topping with no notation of an open date. Walk in egg and dairy cooler: -20 hard boiled eggs were in a Ziploc bag without a notation of a date. -1/4 bottle cherries with an open date of 1/16/24. -one open block of butter with no notation of an open date. -15 pieces of summer sausage in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to maintain wheelchairs in a clean and sanitary manner for 1 of residents (R68) reviewed who utilized wheelchairs. In addition, the facility failed to maintain a standing lift shared by residents in a clean and sanitary manner. Findings include: R68's annual Minimum Data Set (MDS) dated [DATE], identified R68 had moderate cognitive impairment and had diagnosis which included hypertension (elevated blood pressure), non traumatic brain dysfunction and arthritis. Identified R68 required staff assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Further identified R68 utilized a manual wheelchair for mobility. During an observation on 4/9/24 at 9:29 a.m., R68 was seated in his wheelchair at the nurses' station and the left foot pedal of his wheelchair contained a large dried brown food like substance of which covered half of the foot pedal. During an observation on 4/10/24 at 7:40 a.m., R68…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene per Centers for Disease Control and Prevention (CDC) to prevent and/or minimize further spread of COVID-19 for 2 of 3 residents (R45 and R59) reviewed for transmission based precautions. In addition, the facility failed to ensure catheter drainage bags were not placed on the floor for 1 of 1 residents (R62) reviewed for catheters. Findings include: Review of CDC guidance dated 3/18/24, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic indicated health care providers who entered the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety & Health) approved particulate respirator with N95 filters or higher (an N95 respirator is a respiratory protective device designed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.