Eventide Jamestown

Based on information received from the complainant, review of facility policy and resident interviews, the facility failed to ensure reasonable accommodation of needs regarding call lights for 4 of 8 confidential residents (Residents C, D, E, and G. Failure to answer call lights timely, may result in discomfort, increased falls, and/or incontinence.Findings include:Review of the facility policy titled Standards of Care occurred on 08/26/25. This policy, revised August 2024, stated, . Staff will respond to call lights in a timely manner .-During an interview on 08/26/25 at 11:20 a.m., Resident D stated, I have my call light now but sometimes they forget to give it to me. Sometimes it takes a half hour or longer for help. One time I waited on the toilet and had to yell for someone to come.-During an interview on 08/26/25 at 11:30 a.m., Resident E stated, A couple of months ago I had soiled myself in bed and needed to be changed. I waited for almost two hours.-During an interview on 08/26/25 at 11:55 a.m., Resident G stated, Staff run ragged around here and they aren't very nice. One…

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, and confidential resident interviews, the facility failed to provide palatable and attractive food for 5 of 10 confidential residents (Residents B, D, F, G, and H). Failure to ensure residents receive food that is palatable, places residents at risk of weight loss and nutritional decline.Findings include:Review of the lunch menu served on 08/26/25 identified tater tot casserole (hotdish), tomato wedges, pacific blend vegetables, and a sundae brownie. -During an interview on 08/26/25 at 11:20 a.m., Resident D stated, They told me they didn't have anything for me [special diet], so I ordered plain mashed potatoes, but they covered them in gravy, so I didn't eat. -Observation on 08/26/25 at 11:45 a.m. showed a meal tray in Resident F's room. The plate contained two mounds of a brown substance (that did not resemble tater tot casserole) and the resident stated, This is supposed to be tater tot hotdish. The food is terrible. The dietitian gave me Ensure [a supplement] but I get tired of that but there's nothing else to eat. The resident ate only the…

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, review of the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, review of facility policy, and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 14 sampled residents (Resident #5 and #222). Failure to treat residents with dignity, speak respectfully, and provide privacy during toileting has the potential to affect the residents' psychosocial wellbeing and does not enhance the residents' quality of life. Findings include: The North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, updated 03/21/23, stated, . The facility must treat you courteously, fairly and with dignity. Review of the facility policy titled Standards of Care occurred on 05/21/25. This policy, dated August 2024, stated, . Dignity . door to be closed anytime cares are being completed. - Observation on 05/19/25 at 1:23 p.m. showed a certified nurse aide (CNA) (#9) attempted to transfer Resident #5 from the wheelchair to the bed. The resident had difficulty standing up…

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 record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 18 sampled residents (Resident #1 and #55). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2024, page A-32, stated, . Complete if A0310A = 01 . Annual assessment . Coding Instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #1's medical record occurred on all days of survey. The medical record included the diagnosis of schizophrenia, neurocognitive disorder, bipolar, and dementia. The facility failed to code…

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, record review, review of facility policy, and staff interview the facility failed to ensure residents received the necessary services to maintain personal and oral hygiene for 2 of 8 sampled residents (#5 and #52) dependent on staff for personal hygiene. Failure to provide assistance with oral care and personal hygiene may result in poor hygiene, and decreased self-esteem and quality of life. Findings include: Review of the facility policy titled Standards of Care occurred on 05/21/25. This policy, dated December 2023, stated, . Oral cares are provided a minimum of AM [morning] and PM [evening](teeth/dentures cleansed and mouth rinsed or swabbed). Peri-cares are provided after each toileting or brief change . - Review of Resident #5's medical record occurred on all days of survey. The care plan stated, . Self-care deficit . Bathing: assist of 1 . Grooming: assist of 1 . Toileting: Check and change . Assist of 1 . Observation on 05/19/25 at 1:20 p.m., showed Resident #5 sat in the wheelchair in her room, with her pants half off, disheveled hair, and faced…

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, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents for 2 of 9 sampled residents (Resident #5 and #49) observed during transfers. Failure to utilize and/or properly use gait belts and lock wheelchair brakes during transfers placed the residents at risk of injury and/or pain. Findings include: Review of the policy titled Standards of Care occurred on 05/21/25. This policy, dated August 2024, stated, . A gait belt will be used for all assisted transfers . [NAME], [NAME], and Frandsen, Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th edition, eText 2021, Pearson Education, Inc., New Jersey, page 1106, stated, . Positioning a client in good body alignment . are essential aspects of nursing practice . Page 1117, stated, Wheelchair Safety: Always lock the brakes on both wheels of the wheelchair when the client transfers in or out of it.…

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, record review, review of facility policy, and staff interview, the facility failed to provide respiratory care for 1 of 1 sampled resident (Resident #5) with an order for oxygen. Failure to administer oxygen according to physician orders may result in complications and compromise the residents' respiratory status. Findings include: Review of the facility policy titled Oxygen use and Storage occurred on 5/21/25. This policy, dated July 2023, stated, . Oxygen will be administered per practitioner orders . Review of Resident #5's medical record occurred on all days of survey and identified a physician's order, dated 05/14/25, stated, oxygen at 2 liters per minute per nasal cannula. Observation on all days of survey showed Resident #5 without oxygen. During an interview on 05/21/25 at 1:08 p.m., an administrative staff member (#1) stated she expected staff to administer oxygen as ordered.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 14 sampled residents (Resident #43, #49, and #52) and one supplemental resident (Resident #272) observed during cares. Failure to practice infection control standards related to hand hygiene, enhanced barrier precautions (EBP), and disinfecting of mechanical lifts has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 05/21/25. This policy, revised November 2024, stated, . hand hygiene will be done: a. Before and after resident contact (before you leave the room) . After every dirty procedure . Review of the facility policy titled Transmission-Based Precautions occurred on 05/21/25. This policy, revised December 2024, stated, . Enhanced barrier precautions . gown and gloves must be worn during high-contact care activities such as . assisting with toileting . - Observation on 05/19/25 at 12:33 p.m. showed two certified nurse aides…

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 record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 20 sampled residents (Resident #2 and #75). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A - IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2023, pages A-30 through A-32, Section A: . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID [Intellectual Disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. - Review of Resident #2's medical record occurred on all days of survey.…

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, record review, review of the operations manual for the mechanical lift, and staff interview, the facility failed to provide adequate supervision and/or assistive devices for 2 of 20 sampled residents (Resident #29 and #43) with call lights and 1 of 3 sampled residents (Resident #29) with stand lifts. Failure to ensure proper use of a mechanical sit-to-stand lift and/or proper placement of a call lights placed Resident #29 and #43 at risk for injury. Findings include: Review of facility's Operator's Instructions for the [NAME] 3000 Stand Lift, occurred on 04/04/24. The instructions, dated November 2014, stated, . Have patient place feet on the foot plate and position their shins into the shin pad . position the sling around the patient's lower back . with the resident's arms outside the sling . fasten the support strap securely; the strap should be tight, but comfortable for the patient . carefully push the [NAME] 3000 in closer make full lower leg contact with the knee support . fasten…

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 and staff interview, the facility failed to provide confidentiality of electronic medication administration records (eMAR) for 1 of 4 medication carts observed during survey. Failure to close or lock the eMAR may result in unauthorized viewing of confidential resident records by other residents, unlicensed staff, and visitors. Findings include: Observations on 03/14/23 between 8:15 a.m. to 8:30 a.m. identified an unattended medication cart located in the 300 hallway with the computer screen open, revealing a resident's picture, name, medications and dosages. During an interview on 03/16/23, an administrative nurse (#1) confirmed nursing staff are expected to close or lock the computer screen when medication carts are left unattended.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the residents' status for 1 of 1 sampled resident (Resident #58). Failure to accurately complete Section N (medications) of the MDS, may negatively affect the development of a comprehensive care plan, and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2019, page N-7, stated, . N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period. Review of Resident #58's medical record occurred on 03/15/23. The current physician's orders lacked an order for an opioid. A quarterly MDS, dated [DATE], identified staff coded section N for opioid use all seven days of the look-back period. During an interview on 03/16/23 at 8:58 a.m., an administrative nurse…

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, review of professional references, and staff interview, the facility failed to provide assistance and/or assistive devices necessary to ensure safety and prevent accidents or injury for 1 of 9 sampled residents (Resident #40) observed during mechanical sit to stand lift transfers. Failure to transfer residents properly puts the resident at risk for pain, injury, and/or falls. Findings include: Review of the facility policy and procedure document titled Standing lifts occurred on 03/16/23. This document, dated September 2020, stated, . 11. Place the resident's feet on the footplate . 13. Have the resident hold onto the handle grips . 15. Ensure the resident's arms are located outside of the sling . Review of Resident #40's medical record occurred on all days of survey and included a diagnosis of functional quadriplegia and contracture. Observation on 03/14/23 at 10:08 a.m. showed a nurse (#2) and a certified nursing assistant (CNA) (#3) transfer Resident #40 from the wheelchair to the bed and back to the wheelchair with a mechanical sit to stand lift. The…

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 record review, review of professional reference, and resident and staff interview, the facility failed to administer medication in accordance with professional standards for 1 of 1 sampled resident (Resident #45) who reported receiving the wrong type of insulin. Failure to administer the correct insulin may result in adverse health effects for residents. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident. Findings include: [NAME], [NAME], and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., New Jersey, page 835-836, stated, . Certain aspects of medication administration are important for the nurse to check each time a medication is administered. These are referred to as the rights. Right Medication . The medication given was the medication ordered . Right Client . Medication is given to the intended client . Review of Resident #45's medical record…

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.