Eventide Jamestown

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

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 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.

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 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, review of professional reference, and staff interview, the facility failed to ensure appropriate infection control standards during insulin administration for 1 of 1 sampled resident (Resident #45) who reported receiving another resident's insulin. Failure to ensure residents do not share insulin pens may result in the spread of bloodborne pathogens. During a survey started on 03/13/23, the team determined a deficiency existed regarding insulin administration and bloodborne pathogens. Based on the review of the results of the survey, the State Survey Agency (SSA) team determined an Immediate Jeopardy (IJ) situation existed, but this was not conveyed to the facility until 03/21/23. The IJ situation resulted from an interview and record review of Resident #45, who used insulin pens and received insulin from another resident's insulin pen. [...]

Inspectors wroteBased on record review, review of the facility reported incident investigation, review of facility policy and procedure, review of personnel records, and staff interview, the facility failed to immediately start Cardiopulmonary Resuscitation (CPR) on 1 of 1 closed resident record (Resident #179) who requested CPR in the event of absence of pulse or respirations. Failure to immediately start CPR may have contributed to Resident #179's death. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.