Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eventide Lutheran Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a recent right great toe amputation did not consistently have a post-op shoe applied as ordered by the physician. The post-op shoe was omitted from the care plan, and staff were unclear about its use, resulting in the shoe being incorrectly placed or not used at all. Observations and interviews confirmed the lack of proper documentation and communication, leading to the resident's surgical site not being protected as prescribed.
A resident with severe cognitive impairment and on hospice care, who required total assistance with eating, was fed by a hospice RN who stood beside her in the dining room rather than sitting. Interviews with the family, nursing staff, and DON confirmed that standing while feeding does not maintain resident dignity, and facility policy requires dignified care during such assistance.
A resident who was cognitively intact but dependent on staff for certain activities was observed independently using a nebulizer without staff present or proper assessment. Facility records lacked documentation of a self-administration assessment, physician order, or care plan entry authorizing self-administration, despite staff confirming the resident was self-administering after setup. This was not in accordance with the facility's self-medication policy.
A resident with severe cognitive impairment and left-sided weakness did not consistently have her water mug placed within reach, despite care plan instructions and staff awareness of her needs. Multiple observations and interviews confirmed that the water mug was often left out of reach, preventing the resident from accessing fluids independently.
A resident with severe cognitive impairment and dysphagia, able to verbalize food preferences, was not offered meal choices and consistently received a predetermined pureed meal. Staff and dietary personnel confirmed that residents on mechanically altered diets were not given options, and the facility's policy did not address meal choice for these diets.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice, but the facility did not complete a Significant Change in Status Assessment (SCSA) as required. The MDS coordinator missed the assessment due to a miscalculation, and only a quarterly and death MDS were completed. The DON confirmed that timely completion of MDS assessments is expected.
A resident with significant cognitive and physical impairments, identified as at risk for pressure ulcers, was observed in bed without the required Prevalon boots on multiple occasions. Despite care plan directives and staff expectations, nursing assistants did not apply the boots, leaving them on a bedside table. Nursing and administrative staff confirmed the boots should have been used whenever the resident was in bed, but this was not done, resulting in a deficiency in pressure ulcer prevention.
A resident with dementia and a known risk for elopement exited the facility undetected after multiple WanderGuard alarms were triggered. Staff response to the alarms was delayed and incomplete, with searches limited to certain areas and failure to check outside promptly. The resident was missing for several hours before being found by police several miles away, highlighting a breakdown in supervision and adherence to elopement protocols.
Staff did not consistently perform proper hand hygiene or use required PPE during high-contact care activities for two residents on enhanced barrier precautions with indwelling urinary catheters. Observations showed lapses such as not sanitizing hands between glove changes and failing to wear gowns during catheter care, despite facility policy and posted instructions. Staff interviews confirmed these steps were missed, and facility policy required these infection prevention measures.
A resident with impaired cognition and a history of falls fell from a wheelchair and sustained a left humerus fracture due to the facility's failure to follow care plan interventions. The care plan required the removal of foot pedals from the wheelchair and not leaving the resident alone, but these were not adhered to, resulting in the resident attempting to self-transfer and falling.
A resident with dementia and osteoporosis fell from a mechanical lift during a transfer in an LTC facility, resulting in a scalp laceration and sacrum contusion. The incident occurred due to improper securing of the lift sling and failure to position the lift's legs widely for stability. The resident was sent to the ED for treatment.
The facility failed to ensure that food and beverages stored in the refrigerators and freezers were labeled, dated, and discarded properly. Several items were found without proper labeling or dating, and some had visible signs of spoilage. The culinary coordinator and registered dietician confirmed these findings, indicating that the residents had recently been served these items, which should have been discarded according to facility policy.
The facility failed to maintain wheelchairs and a standing lift in a clean and sanitary manner for a resident with moderate cognitive impairment and multiple diagnoses. Observations revealed dried brown food-like substances on the resident's wheelchair pedal and the standing lift. Staff interviews confirmed the presence of the substances and revealed uncertainty about cleaning responsibilities and processes. The facility did not provide a policy on cleaning wheelchairs and lifts when requested.
The facility failed to ensure proper PPE use and hand hygiene per CDC guidelines for two COVID-19 positive residents and did not prevent a catheter drainage bag from being placed on the floor for another resident. Staff did not follow the facility's policies, leading to potential infection risks.
Failure to Follow Physician Orders for Post-Op Shoe After Toe Amputation
Penalty
Summary
A deficiency occurred when the facility failed to ensure physician orders were followed for a resident who had recently undergone a right great toe amputation. The resident, who had severely impaired cognition and a history of physical and verbal behavioral symptoms, returned from surgery with post-operative instructions that included weight bearing as tolerated in a post-op shoe to protect the surgical site. However, the post-op shoe was not included in the resident's care plan or the nursing assistant care plan, and staff were unclear about when and how the shoe should be used. Multiple observations showed the resident without the post-op shoe on the right foot, and at times, the shoe was incorrectly placed on the left foot instead. Interviews with staff revealed confusion and lack of knowledge regarding the post-op shoe order, with some staff believing the shoe should not be used or not knowing which foot it belonged on. The resident's medical history included non-traumatic brain dysfunction, peripheral vascular disease, diabetes mellitus, and Alzheimer's disease, all of which increased the risk for poor wound healing and skin breakdown. The care plan identified risks for skin breakdown and previous pressure ulcers, but did not address the need for the post-op shoe following the amputation. Observations documented the resident sitting in various locations without the protective shoe on the surgical foot, and staff interviews confirmed that the care plan had not been updated to reflect the post-surgical needs. Family members also reported that during their visits, the resident's right foot was not protected as instructed by the post-op orders. Staff interviews further highlighted the lack of communication and documentation regarding the post-op shoe. Nursing staff and nursing assistants were unsure about the presence of an order for the shoe, its purpose, or the correct application. The facility's policy required care plans to be updated with changes in the resident's condition, but this was not done after the resident's surgery. As a result, the resident's surgical site was not consistently protected as prescribed, and staff actions did not align with the physician's post-operative instructions.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, hypertension, and anemia, who was receiving hospice care and required total staff assistance with eating, was not provided a dignified dining experience. The resident was observed in the dining room seated in a reclining wheelchair while a hospice registered nurse (H-RN) stood beside her and assisted her with eating by feeding her with a spoon. This practice was observed on multiple occasions during the meal. Interviews with the resident's family member, the H-RN, another registered nurse (RN-A), and the director of nursing (DON) confirmed that standing while feeding a resident is not considered a dignified practice. The family member expressed dissatisfaction with the staff standing while feeding, and both RN-A and the DON stated that staff are expected to sit while assisting residents with eating to maintain dignity and promote safety. Facility policy also indicated that all residents should receive safe and dignified care.
Failure to Assess and Authorize Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and authorized to self-administer nebulizer medications. The resident, who was cognitively intact but dependent on staff for transfers and toileting due to a hip fracture and right ankle fracture, was observed on multiple occasions independently using a nebulizer in her room without staff present. Documentation review revealed that the resident's care plan and electronic health record did not include any assessment or authorization for self-administration of medications, nor was there a physician's order permitting this practice. The resident's medication orders directed staff to administer the nebulizer treatments, but there was no documentation supporting self-administration. Interviews with facility staff, including an LPN, resident care manager, and DON, confirmed that the required self-administration assessment had not been completed, and the process outlined in the facility's self-medication policy was not followed. The policy required a provider's order, a completed assessment to determine appropriateness, and care plan documentation for self-administration, none of which were present for this resident. Staff acknowledged that the resident was self-administering her nebulizer after staff set it up, despite the lack of required assessments and documentation.
Failure to Ensure Hydration Within Reach for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with severe cognitive impairment and left-sided weakness consistently had access to adequate hydration within reach. The resident, who required partial assistance with eating and had a care plan specifying the need for tray setup and placement of items on her right side, was observed multiple times with her water mug placed out of reach. Family members and staff interviews confirmed that the water mug was often left across the room or on the resident's left side, which she could not access due to hemiparesis from a stroke. The resident herself reported being unable to reach her water mug and experiencing thirst as a result. Observations on several occasions showed the water mug placed behind the resident, across the room, or on the left side, all out of her reach. Staff acknowledged that the standard practice was to keep the water mug next to her, but this was not consistently followed. The facility's policy directed staff to offer fluids during scheduled care but did not specify the need to keep water within reach when appropriate. The director of nursing stated that her expectation was for staff to place water within reach to prevent dehydration, but this was not consistently implemented for the resident.
Failure to Offer Meal Choices to Resident on Pureed Diet
Penalty
Summary
The facility failed to honor a resident's right to make choices about food at meals for a resident with severe cognitive impairment and dysphagia requiring a pureed, nectar-thick diet. Despite the resident's ability to verbalize preferences, staff did not offer meal options, instead providing the same predetermined pureed meal to all residents on similar diets. Interviews with staff, dietary personnel, and family confirmed that the resident was not asked for meal preferences, and the kitchen routinely pureed only the first menu option for these diets. The care plan indicated the resident could feed herself with assistance and had specific beverage preferences, but these were not consistently honored. Observations and interviews revealed that while residents on regular diets were offered meal choices, those on mechanically altered or pureed diets were not, regardless of their ability to express preferences. Staff and dietary management acknowledged this practice, citing concerns about food waste and assumptions about residents' decision-making abilities. The facility's policy on diets did not address the provision of meal choices for residents on modified diets, contributing to the lack of individualized meal options for the affected resident.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process after a resident was admitted to hospice care. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, and traumatic brain injury, required extensive assistance with activities of daily living. Documentation showed that the resident was admitted to hospice, but the electronic medical record did not contain a significant change MDS assessment following this event. Instead, only a quarterly MDS and a death MDS were completed. During interviews, the MDS coordinator acknowledged that the significant change MDS was missed due to a miscalculation of days, and the DON confirmed the findings, stating that MDS assessments are expected to be completed in a timely manner. Facility policy requires initiation of a significant change assessment when the interdisciplinary team determines there has been a significant change in condition.
Failure to Implement Pressure-Relieving Device for Pressure Ulcer Prevention
Penalty
Summary
A resident with severe cognitive impairment, hemiplegia, aphasia, and Parkinson's Disease was identified as being at risk for pressure ulcers and required extensive assistance with activities of daily living, including bed mobility and repositioning. The resident's care plan and treatment administration record specified the use of Prevalon boots while in bed to prevent skin breakdown. Observations on two separate occasions revealed that the resident was in bed without the prescribed Prevalon boots, which were instead found on a bedside table across the room. Nursing assistants did not apply the boots during care, stating they believed the boots were only required at night. Interviews with nursing staff and the DON confirmed that the resident was at risk for pressure ulcers and that the expectation was for the Prevalon boots to be applied whenever the resident was in bed, as outlined in the care plan. Facility policy required necessary treatment and services to prevent new pressure ulcers, but staff failed to implement the prescribed pressure-relieving device as directed, resulting in a deficiency in pressure ulcer prevention care.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dementia, and a history of wandering and elopement risk exited the facility without staff knowledge or intervention. The resident was equipped with a WanderGuard device, and his care plan included supervision, frequent checks, and specific interventions to address his elopement risk. Despite these measures, the resident was able to trigger multiple door alarms and exit the building, remaining missing for approximately five hours before being located by police several miles away from the facility after dark. The sequence of events leading to the deficiency involved several lapses in staff response and supervision. When the resident's WanderGuard triggered alarms at multiple exit points, the receptionist received the alerts and attempted to notify the charge nurse. However, the response was delayed, and staff did not immediately conduct a thorough search of the property or check outside the building. The receptionist missed a critical alarm while away from her desk, and staff searches were limited to certain areas inside the building. Camera footage later confirmed the resident had exited the building, but this was not reviewed in time to prevent his departure. Interviews with staff revealed that expected protocols, such as immediate response to alarms and comprehensive searches, were not fully followed. Staff acknowledged that they should have checked outside as soon as the alarms were triggered and that more proactive measures could have prevented the resident from leaving the premises. The facility's elopement prevention policy required immediate and thorough searches, but these actions were not effectively implemented during the incident, resulting in the resident's prolonged absence and exposure to potential harm.
Removal Plan
- Facility began immediate investigation.
- Upon R1's return to facility a complete head to toe assessment was completed and every 30-minute safety checks were implemented due to risk of reoccurrence.
- All staff mandatory meetings have been held. Education included: elopement, missing resident, facility policies and procedures, and this specific incident and interventions had been discussed.
- Frequent checks will be completed if statements are made about leaving.
- Elopement checks will be completed if R1 makes statements about leaving.
- Elopement drills will be conducted.
- Wander guard system was checked and in working order.
- Policies were reviewed, elopement and missing resident. no changes needed.
- Other high elopement resident charts and care plans were reviewed, and triggers and interventions were added as needed.
- Pictures of high-risk elopement residents had been dispersed to all departments to review routinely. Pictures updated with any changes.
Failure to Follow Hand Hygiene and PPE Protocols During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and personal protective equipment (PPE) practices during high-contact care activities for two residents who were under enhanced barrier precautions (EBP) due to indwelling urinary catheters. Observations revealed that staff did not consistently follow established protocols for hand hygiene and PPE use during catheter care and related activities. Specifically, one nursing assistant, after removing gloves post-catheter care, did not sanitize her hands before donning a new pair of gloves and continued to provide care to the resident. Another nursing assistant failed to wear an isolation gown while emptying a urinary catheter, despite facility signage and policy requiring gown and glove use for such high-risk activities under EBP. The residents involved had significant medical histories, including neurogenic bladder, congestive heart failure, and other chronic conditions, and both required substantial assistance with activities of daily living. Their care plans identified them as being at increased risk for infection due to the presence of indwelling urinary catheters and directed staff to use EBP, including proper hand hygiene and PPE, during all catheter-related care. Despite these directives, staff actions did not align with facility policy or posted instructions, as evidenced by the observed lapses in hand hygiene and PPE use. Interviews with staff and facility leadership confirmed that the expected procedures were not followed. Staff acknowledged the importance of hand hygiene between glove changes and the necessity of wearing gowns and gloves during high-risk care activities, but admitted to forgetting or neglecting these steps during the observed incidents. Facility policies reviewed also emphasized the need for hand hygiene before and after resident contact, before clean procedures, and after dirty procedures, as well as the use of gowns and gloves for EBP residents during high-risk activities.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to follow care planned interventions to ensure the safety of a resident with a history of falls, resulting in actual harm. The resident, who had moderately impaired cognition and required extensive assistance with activities of daily living, fell from a wheelchair and sustained a left humerus fracture. The care plan directed staff to remove foot pedals from the resident's wheelchair when in the room and not to leave the resident alone in the wheelchair, but these interventions were not followed. On the day of the incident, the resident was found on the floor with the wheelchair next to the bed, foot pedals still attached, and the catheter bag in the holder below the wheelchair. The resident attempted to self-transfer back to bed, which led to the fall. The resident was sent to the emergency department and diagnosed with a left proximal humerus fracture. Previous progress notes indicated a history of falls and a high fall risk score, but the care plan interventions were not consistently implemented. Interviews with facility staff confirmed that the care plan required the removal of foot pedals from the wheelchair while the resident was in the room. However, the pedals were not removed at the time of the fall, contributing to the incident. The facility's policy on falls required comprehensive assessments and individualized interventions, but these were not adequately followed, leading to the resident's injury.
Unsafe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer using a full body mechanical lift for a resident, resulting in harm. The resident, who had a history of dementia, recurrent hip dislocation, and osteoporosis, fell from the lift during a transfer. This incident led to a laceration on the back of her scalp and a contusion of the sacrum. The resident was sent to the emergency department and required four staples to the scalp. The incident occurred when two nursing assistants were transferring the resident from her bed to a wheelchair using a mechanical lift. The lift's sling was not properly secured, as one of the loops was not fully nested in the hook, causing the resident to slip out of the sling. Additionally, the mechanical lift's legs were not in the wide position, which is necessary to ensure stability during the transfer. The nursing assistants did not double-check the strap placement before proceeding with the lift, which contributed to the resident's fall. The resident's family had a camera in the room that recorded the fall, showing that the straps were not checked by the second nursing assistant who entered the room. The resident began to lean and fall to the right side, and despite attempts by the nursing assistants to hold her, she slipped out of the sling and hit her head on the floor. The facility's investigation confirmed that the sling was not appropriately hooked up, leading to the resident's fall and subsequent injuries.
Removal Plan
- Recertification of mechanical lift usage for all nursing staff.
- Immediate education and demonstration of mechanical lift competencies for all nursing staff involved in the incident.
- All nursing staff required to complete a mechanical lift competency prior to their next shift.
- Email sent to all nursing staff with mechanical lift competency instructions and pictures of correct and incorrect sling positioning.
- Mechanical lift audits conducted to ensure correct usage.
- Immediate staff education and audits initiated after the fall.
- Plan to provide education to approximately five to seven PRN staff prior to their next shift.
Failure to Properly Label, Date, and Discard Food and Beverages
Penalty
Summary
The facility failed to ensure that food and beverages stored in the refrigerators and freezers were labeled, dated, and discarded properly. During an initial tour of the kitchen area, several items were found without proper labeling or dating, including hard-boiled eggs, enchilada sauce, mustard, whipped topping, cherries, butter, summer sausage, Swiss cheese, gluten-free bread, and nectar thick ice cubes. Additionally, various items in the juice cooler, main freezer, hall freezer, basement freezer, first-floor kitchen refrigerator, and first-floor kitchen freezer were also found without proper labeling or dating, and some items had visible signs of spoilage such as ice crystals and crusty flakes around the lids. The culinary coordinator confirmed these findings and indicated that the residents had recently been served these items, which should have been discarded according to facility policy. The registered dietician also confirmed that the expectation was for all food to be dated when opened and discarded per facility policy. The facility's policy on cold storage, revised in January 2018, indicated that all perishable refrigerated and frozen items were to be stored according to state and federal regulations, and all food must be labeled, dated, and properly sealed. The failure to adhere to these standards had the potential to affect all 116 residents who received food and beverages from the facility's refrigerators and freezers.
Failure to Maintain Clean and Sanitary Equipment
Penalty
Summary
The facility failed to maintain wheelchairs and a standing lift in a clean and sanitary manner for a resident with moderate cognitive impairment and multiple diagnoses, including hypertension, non-traumatic brain dysfunction, and arthritis. The resident required staff assistance with activities of daily living and used a manual wheelchair for mobility. Observations revealed a large dried brown food-like substance on the left foot pedal of the resident's wheelchair on two consecutive days. Additionally, a standing lift in the hallway had a similar dried brown food-like substance on its lower end. Interviews with staff, including a nursing assistant, housekeeper, and the director of nursing, confirmed the presence of the dried brown substance on both the wheelchair pedal and the standing lift. The nursing assistant and housekeeper were unsure of the cleaning responsibilities and processes for wheelchairs and lifts. The director of nursing indicated that the night shift was responsible for cleaning resident wheelchairs on their bath day and as needed, while housekeeping was responsible for cleaning the lifts. However, the facility did not provide a policy on cleaning wheelchairs and lifts when requested.
Deficiencies in PPE Use and Catheter Care
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene as per CDC guidelines to prevent the spread of COVID-19 for two residents who tested positive for the virus. Observations revealed that a nursing assistant (NA) did not wear an N95 mask or eye protection while transporting a COVID-19 positive resident and failed to perform hand hygiene. Another NA improperly doffed an N95 mask and placed it on a clean box of gloves without sanitizing her hands. Additionally, a third NA was observed wearing an N95 mask incorrectly before entering a COVID-19 positive resident's room. These actions were contrary to the facility's policy and CDC guidelines, which require the use of an N95 mask, gown, gloves, and eye protection when caring for COVID-19 positive residents and proper hand hygiene practices when donning and doffing PPE. The infection preventionist and director of nursing confirmed these observations and stated that the staff did not meet the expected standards for PPE use and hand hygiene. The facility's policy on COVID-19 and CDC guidelines were not followed, leading to potential risks of infection transmission among residents and staff. The facility also failed to ensure that a resident's urinary catheter drainage bag was not placed on the floor, which could lead to contamination and infection. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, was observed with the catheter drainage bag resting directly on the floor. Both a nursing assistant and a licensed practical nurse confirmed that the bag should have been placed in a dignity bag or basin to prevent contamination. The infection preventionist and director of nursing reiterated that the facility's policy required catheter drainage bags to be kept off the floor to prevent infection. The facility's failure to adhere to these policies and guidelines resulted in deficiencies in infection prevention and control practices.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Moorhead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Meadows On University | 1.4 mi | ★★★★★ | 2 | 0 |
| Smp Health - St Catherine South | 1.5 mi | ★★★★★ | 0 | 0 |
| Bethany On University | 1.6 mi | ★★★★★ | 3 | 0 |
| Smp Health - St Catherine North | 2.6 mi | ★★★★★ | 4 | 0 |
| Fargo Elim Health Care Center | 2.9 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.