Eventide Jamestown

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Mar 22, 2023

  Based 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. […]

• Actual harm, isolatedF678Mar 22, 2023

  Based 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. Findings include: Review of the facility policy and procedure titled CPR/AED [Cardiopulmonary Resuscitation /Automated External Defibrillator] CODE LEVEL occurred on [DATE]. This policy, revised [DATE], stated, . […]

• No harm, potential for more than minimal, widespreadF727Jul 23, 2026

  Based on review of nurse staffing schedules and staff interview, the facility failed to provide the services of a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 2 of 45 days reviewed (07/04/26 and 07/05/26). Failure to ensure sufficient, qualified nursing staff are available eight consecutive hours a day has the potential to affect the health and safety of all the residents residing in the facility. Findings include:On 07/20/26, the facility provided a copy of the nurse staffing schedules for the period of June 14-July 18, 2026. A review of the schedules showed the facility failed to have the required RN coverage on 07/04/26 and 07/05/26. […]

• No harm, potential for more than minimal, widespreadF801Jul 23, 2026

  Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#5) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services may place residents at risk for adverse nutritional needs. Findings include: During an interview on 07/20/26 at 9:55 a.m., the dietary director (#5) stated she is currently enrolled in a certified dietary manager (CDM) program through University of North Dakota (UND) and has not completed a certified program. […]

• No harm, potential for more than minimal, widespreadF838Nov 3, 2021

  Based on record review and staff interview, the facility failed to conduct a facility-wide assessment to evaluate the resident population and identify the resources needed to competently provide care and services to residents during both day-to-day operations and emergencies. This failure has the potential to affect all residents residing in the facility. Findings include: Review of the Facility Assessment on 11/03/21 showed it lacked information related to personnel listing and staff competencies and lacked completed information related to medical and non-medical equipment. During an interview on 11/03/21 at 2:56 p.m., an administrative staff member (#1) confirmed the current facility assessment lacked all required elements.