Eventide Heartland

In the surveyor’s words

From the most serious findings on record at Eventide Heartland, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 22, 2022

  Based on record review, review of facility policies, incident reports, and staff interview, the facility failed to investigate a fall, report a change in condition to the physician in a timely manner, and promptly and thoroughly investigate an injury of unknown origin for 1 of 2 sampled residents reviewed for falls (Resident #1). These failures resulted in Resident #1 experiencing unnecessary pain, and placed all residents at risk for falls, abuse, neglect, lack of treatment and/or unnecessary pain. During an on-site facility incident investigation on 08/17/22, the surveyor determined a potential Immediate Jeopardy (IJ) situation existed. […]

• Actual harm, isolatedF600Feb 15, 2023

  Based on record review, review of facility policies/procedures, review of the facility's investigation reports, and staff interviews, the facility failed to ensure freedom from neglect for 1 of 1 closed resident record (Resident #3) who experienced exposure of his/her body while residing in the facility. Failure of staff to provide supervision/assistance unnecessary exposure of Resident #3 ' s body in public areas of the facility and may have resulted in emotional distress and loss of dignity. Findings include: Review of the facility policy titled Vulnerable Adult -North Dakota occurred 02/15/23. This policy, revised May 2022, stated, . Neglect - failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• No harm, potential for more than minimal, patternF759Apr 30, 2025

  Based 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. Findings include: Review of the facility policy titled Medication - Administration and Storage occurred on 04/30/25. This policy, dated March 2025, stated, . […]

• No harm, potential for more than minimal, patternF557Aug 22, 2022

  Based on information provided by the complainant, observation, record review, and staff interview, the facility failed to promote care in a manner that maintained or enhanced the residents' dignity for 5 of 12 sampled residents (Resident #1, #2, #5, #12, and #15) who required assistance with dressing. Failure to ensure residents the residents wore clean, unsoiled clothing does not promote mental well-being and may lead to a resident's loss of dignity. Findings included: The complainant indicated the facility failed to change residents' soiled clothing. - Review of Resident #15's medical record occurred on all days of survey. […]

• No harm, potential for more than minimal, patternF584Aug 22, 2022

  Based on information provided by the complainant, observation, review of facility policy, and resident and staff interviews, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 10 of 62 resident rooms (Room #3, #10, #13, #15, #16, #32, #48, #49, #58, and #59) observed during the survey. Failure to maintain a clean, comfortable, and sanitary environment does not provide a homelike living area for residents. Findings include: Information provided by the complainant indicated the facility failed to provide a clean and sanitary environment in the resident ' s rooms. Review of the facility policy titled Proper Cleaning of a Room occurred on 10/12/22. This policy, dated April 2017, stated, . […]