Deficiency Records for Eventide Lutheran Home
Updated as of May 01, 2024
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Deficiency Records for Eventide Lutheran Home
A list of the most recent deficiencies for Eventide Lutheran Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Eventide Lutheran Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-15 | 2023-10-04 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-08-16 | 2023-09-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-08-16 | 2023-09-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-16 | 2023-09-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-16 | 2023-09-18 | N |
| Post nurse staffing information every day. | Health | 2023-08-16 | 2023-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-16 | 2023-09-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-16 | 2023-09-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-16 | 2023-09-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-15 | 2023-09-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-15 | 2023-09-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-15 | 2023-09-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-15 | 2023-09-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-15 | 2023-09-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-15 | 2023-09-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-03 | 2023-05-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-03 | 2023-05-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-28 | 2023-04-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-01 | 2023-01-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-01 | 2023-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2023-01-16 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-15 | 2022-07-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-11 | 2022-04-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-11 | 2022-04-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-11 | 2022-04-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-11 | 2022-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-11 | 2022-04-15 | N |
| Report COVID19 data to residents and families. | Health | 2022-03-11 | 2022-04-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-11 | 2022-04-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-11 | 2022-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-04-15 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-03-11 | 2022-04-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-09 | 2022-04-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-09 | 2022-04-08 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-09 | 2022-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-09 | 2022-04-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-03 | 2021-12-10 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-02 | 2021-10-22 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-09-02 | 2021-10-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-12 | 2019-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-12 | 2019-10-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-12 | 2019-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-12 | 2019-10-26 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-08-12 | 2019-09-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-08-12 | 2019-09-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-12 | 2019-09-20 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-12 | 2019-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-12 | 2019-09-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-12 | 2019-09-20 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-08-12 | 2019-09-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-06 | 2019-09-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-06 | 2019-09-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-06 | 2019-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-06 | 2019-08-09 | N |
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