Eventide Lutheran Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 30, 2025

  Based 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. […]

• Actual harm, isolatedF689Jun 24, 2026

  Based 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. […]

• Actual harm, isolatedF689Mar 12, 2025

  Based 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. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderately impaired cognition with diagnoses of type two diabetes, dementia, anxiety and depression. […]

• Actual harm, isolatedF689Dec 10, 2024

  Based 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. […]

• Actual harm, isolatedF689Sep 15, 2023

  Based 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). Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition with no behaviors, extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. R2 was not on a toileting program, had frequent bladder incontinence and continent of bowel. R2 received anticoagulants and antidepressants 7 out of the 7 days during the look back period. R2 had three falls since admission, one without injury and two with minor injuries. […]