Eventide Lutheran Home

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide care consistent with a resident's needs and care plan to eliminate/reduce the risk of an accident in bed for 1 of 1 residents (R1). This resulted in actual harm to R1 when she rolled out of bed onto the floor. R1's fall mat was not alongside the bed and her call light was not within reach. As a result, R1 was transported to the emergency department (ED) on 6/12/26, for a laceration to the forehead and a fracture to her right clavicle. The facility had implemented actions to prevent recurrence prior to the survey on 6/23/26, therefore, the citation was issued at past non-compliance. Additionally, the facility failed to provide adequate supervision and secure transportation for R2 who has severe cognitive impairment.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R95) had adequate hydration within reach.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure adequate supervision for 1 of 3 residents (R1) reviewed for accidents. This failure resulted in an immediate jeopardy (IJ) when R1 eloped from the facility, and was found 5 hours later, approximately 4 miles from the facility, after dark. The IJ began on 4/16/25 at 6:27 p.m., when R1 exited an alarmed door at the facility and staff failed to respond timely and complete a full property search for R1. R1 was located by the police approximately four miles from the facility at 12:00 a.m. Director of quality and infection prevention and director of clinical services were notified of the IJ at 5:15 p.m. on 4/30/25. The facility implemented corrective action by 4/22/25, prior to the start of the survey and therefore is issued as past non-compliance.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow care planned interventions to ensure resident's safety for 1 of 3 residents (R1) who had a history of falls. This resulted in actual harm for R1 when he fell from the wheelchair, was sent to the emergency department (ED) and sustained a left humerus fracture. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a safe transfer using a full body mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in harm for R1 when she fell from the lift during a transfer, sustained a laceration to the back of her scalp and contusion (a bruise caused by blood vessels under the skin that break and bleed due to an injury such as a blow or impact) of the sacrum (a bone that connects the lumbar spine and the pelvis). R1 was sent to the emergency department (ED) and required four staples to the scalp. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure interventions were implemented to reduce the fall risk for 1 of 3 residents (R2) reviewed for accidents. This deficient practice caused actual harm when R2 fell and sustained a left fractured patella (knee cap).