Eventide Heartland

Inspectors wroteBased on record review, review of facility policy and staff interview, the facility failed to fully inform the resident or resident's representative regarding treatment with psychotropic medications for 1 of 5 residents (Resident #8) reviewed for unnecessary medications. Failure to fully inform the resident or resident's representative of the risks, benefits, or alternative options for psychotropic medications does not allow residents the right to choose treatment options.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to provide privacy for 2 of 3 sampled residents (Resident #15 and #27) observed during personal cares while positioned in a mechanical sit-to-stand lift. Failure to ensure privacy during personal care infringes on the resident's rights and does not enhance their quality of life.

Inspectors wroteBased on observation, record review, review of facility policy and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 1 of 1 supplemental residents (Resident #60) on oxygen. Failure to clean personal fans does not provide a safe and clean environment and may place the resident at risk for illness.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 17 sampled residents (Resident #5 and #9). 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.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents for 3 of 5 sampled residents (Resident #8, #15, and #27) observed during transfers with a mechanical sit-to-stand lift. Failure to properly utilize a mechanical sit-to-stand lift during transfers placed the residents at risk for injury and falls.

Inspectors wroteBased on observation, record review, review of the dialysis contract, review of the dialysis communications forms, and staff interview, the facility failed to provide care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #7) receiving hemodialysis. Failure to complete dialysis treatment communications may result in an unidentified change in the resident's condition.

Inspectors wroteBased on observation, review of facility policy, review of professional reference and staff interviews, the facility failed to label over the counter (OTC) medications in accordance with professional standards for 2 of 2 medication carts. Failure to ensure appropriate and legible labels placed residents at risk for potential medication errors.

Inspectors wroteBased on observation, review of professional references, and staff interview, the facility failed to follow professional standards of infection control and prevention for 2 of 9 sampled residents (Resident #15 and #30) observed during cares. Failure to practice infection control standards related to hand hygiene, glove use, and when emptying catheter bags has the potential to spread infection throughout the facility.

Inspectors wroteBased on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from physical abuse for 1 of 1 sampled resident (Resident #1) who displayed physical and verbal aggression toward other residents. Failure to ensure an environment free from physical and verbal abuse placed all residents at risk for injury, fear, anxiety, and/or psychosocial harm. Findings Include:Review of the facility policy titled Vulnerable Adult - North Dakota occurred on 04/08/26. This policy, dated February 2026, stated, . Vulnerable Adult - Every resident of the facility . Abuse - the willful infliction of injury . Physical abuse - conduct that produces pain or injury and is not accidental . Examples of abuse . resident to resident abuse . A FRI report, dated 02/14/26, stated, . [...]

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 3 sampled residents (Resident #3 and #6) observed during cares and 1 of 1 sampled resident (Resident #7) observed during a dressing change. Failure to practice infection control standards related to glove usage and hand hygiene has the potential to spread infection throughout the facility. Findings Include:Review of the facility policy titled Hand Hygiene occurred on 04/09/26. This policy, dated February 2026, stated, . Hand hygiene will be done: A. Before and after resident contact (before you leave the room). B. Before every clean procedure. C. After every dirty procedure. The purpose is to prevent the spread of infection.-Observation on 04/08/26 at 1:00 p.m. [...]

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 5 of 7 residents (Resident #2, #19, #20, #21, and #58) observed during medication administration. Thirteen medication errors occurred during staff administration of 37 medications, resulting in a 35% error rate. Failure to properly prime insulin pens and administer medications at the correct time may result in residents receiving an ineffective and/or inaccurate dose and experience adverse reactions.

Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 20 sampled residents (Resident #29 and #58). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident.

Inspectors wrote1. Based on observation, record review, policy review, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 7 residents (Resident #19) observed during medication administration. Failure to document medications at the time of administration does not reflect the actual time of administration and may cause adverse effects for the resident.

Inspectors wroteBased on observation, record review, review of facility policy, review of operator's instructions, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 4 residents (Resident #9) observed during a sit-to-stand mechanical lift transfer. Failure to utilize a mechanical lift properly, complete a nursing assessment, and implement a safe transfer method placed Resident #9 at risk for pain and/or injury.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 3 of 14 sampled residents (Resident #19, #25 and #46) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure posting of accurate and complete staffing information on 1 of 4 days of survey (April 27, 2025). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident and/or the resident's representative a written bed hold notice for 1 of 1 closed record (Resident #10) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representatives to make an informed decision regarding their care.

Inspectors wroteBased on record review, review of the facility reported incident and investigation documents, and review of facility policy, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 resident (Resident #1) who fell during a mechanical stand lift transfer. Failure to provide two-person assistance and failure to utilize the shin strap resulted in Resident #1's fall from the stand lift, injury, and placed all residents transferred via a stand lift at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

Inspectors wroteBased on record review, facility incident report, and staff interview, the facility failed to ensure a complete and accurate medical record for 1 of 4 sampled residents (Resident #9) reviewed for resident-to-resident altercations. Failure to have a complete and accurate medical record limited staff's access to the most recent medical information regarding the residents.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/15/23. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure reasonable accommodation of needs regarding call lights for 1 of 3 sampled residents (Resident #227) with a soft touch call light. Failure to place Resident #227's call light within reach may result in an inability to call for help, discomfort, increased falls, and/or incontinence.

Inspectors wroteBased 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 1 of 22 sampled residents (Resident #1). 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.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's current status for 1 of 22 sampled residents (Resident #227). Failure to revise the care to reflect Resident #227's current status limited the staff's ability to communicate needs and ensure continuity of care for residents.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/20/23. 1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 4 sampled residents (Resident #227) observed during stand lift transfers. Failure to ensure staff utilized the correct lift during transfers caused Resident #227 discomfort/pain and placed him at risk for possible injury.