Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Heartland during CMS and state inspections, most recent first.
A resident with insomnia was ordered Mirtazapine for daily use, but the record lacked evidence that the resident or representative was fully informed about the risks, benefits, or alternative options for the psychotropic medication. The facility policy required informed consent before initiation, and an administrative nurse confirmed there was no consent form in the record.
Failure to maintain privacy during personal care occurred when staff did not close the blinds while assisting two residents with brief changes and toileting in a sit-to-stand lift. In both observations, the residents' buttocks were exposed to the courtyard during care, despite facility policy requiring the privacy curtain or door to be closed anytime cares are being completed.
A resident on O2 with respiratory failure, COPD, SOB, and OSA was observed in a room with a personal fan covered in dust and blowing air directly on the resident. Staff gave conflicting accounts of whether housekeeping or maintenance was responsible for cleaning the fan, and survey observations showed the dust remained on the fan during the survey.
The facility failed to accurately code the MDS for two residents. One resident had documented schizophrenia spectrum and psychotic disorder, but the annual MDS did not code PASRR/serious mental illness items. Another resident was receiving Gabapentin three times daily, but the quarterly MDS did not code anticonvulsant use. An admin staff member confirmed the coding errors.
Improper Use of Mechanical Sit-to-Stand Lift During Resident Transfers: Staff failed to properly use a mechanical sit-to-stand lift during transfers for multiple residents. One resident was transferred without removing heel boots as directed, another was left hanging in the lift after letting go of the handlebars while the CNA continued care, and two CNAs completed a transfer without securing the sling around a resident’s abdomen.
A resident receiving hemodialysis three times weekly had dialysis communication forms that were not completed correctly by facility staff. Review of 42 dialysis visits showed the resident assessment section was left incomplete on most forms, and several additional forms lacked a name and/or date. Two administrative staff confirmed the forms were not accurately completed.
Illegible OTC Medication Labels on Medication Carts: The facility failed to ensure OTC meds were labeled according to accepted standards on 2 medication carts. An MA administered AZO D-Mannose with an illegible pharmacy label covering the drug facts and dosage information, stating she knew the dose from experience, and a nurse was observed with a clear bottle of Iron 325 mg that had an illegible pharmacy label and a handwritten sticker on the cap. An administrative nurse confirmed the pharmacy should replace labels when they become illegible.
Infection control standards were not followed during catheter care and resident assistance for two residents. CNAs drained urine from catheter bags and closed the spouts without sanitizing them, and during perineal care for one resident, a CNA removed soiled gloves, put on clean gloves without hand hygiene, and continued with both dirty and clean tasks using the same gloves before finally removing PPE and cleaning hands.
A resident with Alzheimer's disease, anxiety, moderate cognitive impairment, and a known history of physical and verbal aggression repeatedly exhibited abusive behaviors toward other residents, including shoving, slapping, swinging, and yelling at them, as documented in multiple progress notes and the care plan. Video from a reported incident showed this resident exiting another resident’s room, approaching a male resident in the hallway, and pushing him to the floor before quickly leaving, consistent with the facility’s policy definition of resident-to-resident physical abuse. The medical record did not contain documentation of this specific pushing incident, despite the facility’s awareness of the resident’s ongoing aggressive behaviors and stated expectations that staff monitor, intervene, and report such events.
Surveyors found that staff failed to follow the facility’s hand hygiene policy and proper glove use during a wound dressing change and multiple episodes of personal and toileting care. A nurse performing a dressing change did not remove soiled gloves after disinfecting a bedside table and did not perform hand hygiene between glove changes while cleansing and redressing a wound. In separate observations, CNAs providing perineal care, toileting assistance, and hygiene for two residents repeatedly removed soiled gloves and donned clean gloves without performing hand hygiene, and continued dressing, repositioning, and transferring the residents without required hand cleansing between glove changes.
A facility failed to provide a written bed hold notice to a resident and/or their representative during a hospital transfer. The policy requires obtaining signatures on the Notice of Transfer and Bed Hold form, providing a signed copy to the resident or responsible party, and ensuring a copy accompanies the resident to the hospital. However, the medical record lacked evidence of this documentation, which was confirmed by an administrative staff member.
A resident fell and sustained an injury during a mechanical stand lift transfer due to inadequate supervision and assistance. The CNA involved did not wait for a second staff member and failed to secure the leg straps, contrary to the resident's care plan. This incident placed all residents using the lift at risk.
The facility failed to maintain a complete and accurate medical record for a resident involved in an altercation with another resident. Staff intervened when they overheard elevated voices and found two residents attempting to take a walker from one another, with no physical contact noted. The medical record of a resident with Alzheimer's Disease lacked documentation of the incident, which was confirmed by an administrative nurse who expected documentation for both residents involved.
The facility failed to ensure call light accessibility for a resident with a history of falls. The resident was observed attempting to get out of bed without a call light within reach and was later left alone in a Broda chair without a call light. This was against the facility's policy and the resident's care plan.
The facility failed to accurately code the MDS for a resident, incorrectly indicating that the resident received an antipsychotic medication within the 7-day look-back period, despite no supporting documentation. The MDS coordinator confirmed the miscoding error.
The facility failed to update a resident's care plan to reflect the need for a full-body mechanical lift for transfers. Two CNAs used an incorrect sit-to-stand lift, which was unsuitable as the resident could not bear weight. An administrative nurse confirmed the care plan was not updated, limiting staff communication and continuity of care.
The facility failed to ensure adequate supervision and assistance to prevent accidents and elopements. One resident experienced discomfort and pain due to incorrect lift usage during transfers, while another resident with severe cognitive impairment eloped from the Memory Care Unit twice due to inadequate staff coverage and failure to follow protocols.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to fully inform a resident or the resident's representative regarding treatment with psychotropic medication for one resident reviewed for unnecessary medications. Review of the facility's Psychotropic Medication Use policy showed that informed consent for psychotropic medications was to be obtained from the resident or resident representative before initiation, and that information on the medication was to be provided and documented in the medical record. Review of the resident's record showed a diagnosis of insomnia and a physician order for Mirtazapine, an antidepressant, given one time a day for insomnia. The medical record lacked evidence that the facility fully informed the resident or the resident's representative of the risks, benefits, or alternative options for the psychotropic medication. During interview, an administrative nurse confirmed the record lacked a consent form for psychotropic medication.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when staff failed to provide privacy during personal care for 2 of 3 sampled residents. On 05/18/26, Resident #27 was observed upright in a mechanical sit-to-stand lift while two CNAs completed a brief change, and the blinds in the resident's room were not closed, leaving the resident's buttocks exposed to the courtyard. On 05/19/26, Resident #15 was observed positioned in a sit-to-stand lift and seated on the toilet; a CNA raised the resident from the toilet, performed perineal care, and wheeled the resident out of the bathroom to the room, but the blinds in the resident's room were not closed and the resident's buttocks were exposed to the courtyard. Facility policy titled Standards of Care stated that the privacy curtain/door is to be closed anytime cares are being completed, and an administrative staff member stated staff were expected to close window coverings prior to resident cares.
Dusty Personal Fan in Resident Room
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for one supplemental resident who was on oxygen. The resident’s diagnoses included acute and chronic respiratory failure with hypoxia, COPD, shortness of breath, and obstructive sleep apnea. Survey observations on all days showed a layer of dust on the cover/grate and blades of the resident’s personal fan in the room. On 05/19/26 at 5:00 p.m., the resident was observed seated in the room with oxygen via nasal cannula while the dusty fan was blowing air directly on the resident. Facility staff gave conflicting information about who was responsible for cleaning the fan: a housekeeping staff member stated the fans are cleaned by maintenance, while a maintenance staff member stated housekeeping should clean the resident’s fans during each scheduled room cleaning.
MDS Coding Errors for Serious Mental Illness and Anticonvulsant Use
Penalty
Summary
The facility failed to ensure accurate coding of the MDS for 2 of 17 sampled residents, Resident #5 and Resident #9. Review of the RAI 3.0 User’s Manual and the residents’ records showed that the MDS did not reflect information documented in the chart for each resident. For Resident #9, the medical record reviewed throughout the survey identified diagnoses of schizophrenia spectrum and psychotic disorder, but the annual MDS failed to code Section A1500 and A1510 for serious mental illness. For Resident #5, the medical record showed current use of Gabapentin three times a day, which is an anticonvulsant medication, but the quarterly MDS failed to code Section N0415K1 for anticonvulsant use. An administrative staff member confirmed both coding errors during interview.
Improper Use of Mechanical Sit-to-Stand Lift During Resident Transfers
Penalty
Summary
The facility failed to properly utilize assistive devices needed for safe transfers for 3 of 5 sampled residents observed with a mechanical sit-to-stand lift. The facility policy on standing lifts stated the resident must be able to balance and bear weight, and that the sling should be placed behind the back, with the wings positioned under the arms and the buckle secured around the lower abdomen and pulled snug. During observation, a CNA transferred one resident from bed to wheelchair with the mechanical sit-to-stand lift without removing the resident’s Prevalon boots, even though the care plan stated the boots were to be removed only for transfers and proper footwear was required for all transfers. A second resident, whose care plan directed PAL assist x1 for all transfers, was observed seated on a toilet while a CNA used a mechanical sit-to-stand lift. The resident briefly held the handlebars, then let go and remained hanging in the lift while the CNA continued care and transferred the resident into a recliner. A third resident, also care planned for transfer with PAL, was observed being transferred by two CNAs with a mechanical sit-to-stand lift while the sling straps were left unsecured around the resident’s abdomen. The surveyor questioned the straps, and one CNA stated the other CNA forgot to secure the sling, but both CNAs continued and completed the transfer without securing it.
Incomplete Dialysis Communication Forms
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services. The facility failed to provide care and services consistent with professional standards of practice for one resident receiving hemodialysis. The resident had a physician’s order for hemodialysis three times weekly on Mondays, Wednesdays, and Fridays. Review of the dialysis communication forms between the facility and the dialysis center for 42 visits showed that the facility failed to complete the resident assessment section before the resident’s dialysis appointment on 35 of the 42 forms. In addition, five other dialysis communication forms in the resident’s medical record lacked a name and/or date. The dialysis contract stated that both the ESRD center and the SNF are responsible for collaboration necessary to provide dialysis care coordination to each SNF resident receiving dialysis treatments. During interview, two administrative staff members confirmed that facility staff failed to accurately complete the dialysis communication forms.
Illegible OTC Medication Labels on Medication Carts
Penalty
Summary
The facility failed to label over-the-counter (OTC) medications in accordance with accepted professional principles for 2 of 2 medication carts. Facility policy titled Medication Administration and Storage stated that medications will be labeled according to accepted pharmacy standards, and a professional reference stated to always check the medication label to make sure the correct medication is being taken. During observation, a medication aide administered AZO D-Mannose, an OTC medication for urinary tract health, with an illegible pharmacy label covering the drug facts and dosage information. The physician's order was for AZO D-Mannose 500 mg capsule by mouth once daily, and when asked about the label, the medication aide stated the label covered the dose capsule serving amount but that from experience and administering it for so long, the aide knew it was one capsule. In a separate observation, a medication cart contained a clear bottle with an OTC medication and an illegible pharmacy label; a sticker on the bottle cap stated Iron 325 mg. The nurse stated the pharmacy medication labels fade out and the facility placed a handwritten label on the OTC bottle to identify the medication. An administrative nurse later confirmed the pharmacy should replace labels when they are illegible.
Infection Control Failures During Catheter Care and Resident Assistance
Penalty
Summary
The facility failed to follow infection control and prevention standards during care for two residents with urinary catheters and during personal care for one of those residents. For Resident #15, a CNA entered the room, opened the catheter drainage spout, drained urine into a graduate container, and then closed and secured the spout without sanitizing it. For Resident #30, a CNA performed the same sequence of care, draining urine from the catheter bag into a graduate container and closing the spout without sanitizing it afterward. During care for Resident #15, a CNA wore a gown and gloves while providing perineal care, then removed the soiled gloves and put on clean gloves without performing hand hygiene. The CNA then continued care with the same gloves, applying a clean brief, pulling up the resident's pants, transferring the resident to a recliner, operating the recliner remote, removing the sling around the resident's waist, moving a pillow from the bed behind the resident's head, placing a blanket on the resident's lap, and rearranging items on the bed. The CNA removed the gown and gloves and performed hand hygiene only after completing these tasks. An administrative staff member confirmed hand hygiene was a concern.
Failure to Prevent Ongoing Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when a resident with Alzheimer's disease and anxiety, who had a documented history of physical and verbal aggression toward others, pushed another resident to the floor. The facility’s own policy defined abuse as the willful infliction of injury, including resident-to-resident abuse. A facility reported incident (FRI) described video footage showing the aggressive resident exiting another resident’s room, approaching a male resident in the hallway who had not come near that room, and pushing him down before quickly leaving the area. The FRI also noted that this resident had a history of targeting male residents in the memory care unit. Review of the aggressive resident’s medical record showed a BIMS score of 9, indicating moderate cognitive impairment, and a care plan noting that the resident had hit, pinched, pushed staff when they were helping other residents, and yelled at staff and other residents. Progress notes documented multiple prior episodes of aggression toward other residents, including shoving residents out of the way in the dining room, grabbing a resident’s shirt and shoving him, raising a fist toward another resident, slapping a resident’s arm, swatting at a resident, throwing a blanket at a resident, shoving a chair at a resident, swinging a male resident around by the hand, and repeated verbal aggression. The medical record lacked documentation of the specific incident on the date of the FRI when the resident pushed another resident to the floor. An administrative nurse acknowledged awareness of the resident’s behaviors toward others and stated an expectation that staff monitor residents, intervene immediately, and report incidents, but the facility failed to protect other residents from verbal and/or physical abuse by this resident.
Failure to Follow Hand Hygiene and Glove Use Standards During Resident Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to noncompliance with its hand hygiene policy and improper glove use during resident care and a dressing change. The facility’s hand hygiene policy, dated February 2026, required hand hygiene before and after resident contact, before every clean procedure, and after every dirty procedure to prevent the spread of infection. During a wound dressing change for Resident #7, a nurse performed initial hand hygiene, donned PPE, and disinfected the bedside table, but did not remove soiled gloves after disinfecting the table and did not perform hand hygiene between multiple glove changes while removing a soiled dressing, cleansing the wound, and applying a new dressing and sock. Hand hygiene was only performed once at the end of the procedure after PPE removal. Additional observations showed similar failures by CNAs during personal and toileting care for Residents #3 and #6. For Resident #3, two CNAs performed initial hand hygiene before entering the room, but one CNA removed soiled gloves after perineal care and application of barrier cream and then applied clean gloves without performing hand hygiene; both CNAs later removed soiled gloves and continued dressing and repositioning the resident without hand hygiene between glove changes. For Resident #6, two CNAs performed hand hygiene before entering the room, but one CNA repeatedly removed soiled gloves and applied clean gloves without hand hygiene while handling a soiled brief, removing and washing socks and stockings, performing upper body hygiene, dressing the resident, obtaining wipes, and completing perineal care, and both CNAs transferred the resident after removing soiled gloves without performing hand hygiene. An administrative nurse confirmed that staff were expected to follow the facility’s hand hygiene policy.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident and/or the resident's representative during a hospital transfer. The facility's policy, revised in October 2021, requires the Social Worker or designee to review and obtain signatures on the Notice of Transfer for hospitalization and the Bed Hold form, provide a signed copy to the resident or responsible party, ensure a copy accompanies the resident to the hospital, and file the signed forms in the resident's electronic health record. However, upon reviewing the medical record of a resident who was transferred to the hospital, it was found that the documentation lacked evidence of a written bed hold notice being provided. An administrative staff member confirmed this oversight during an interview.
Inadequate Supervision During Lift Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide appropriate supervision and assistance during a mechanical stand lift transfer, resulting in a fall and injury for one resident. The incident occurred when a certified nurse aide (CNA) attempted to transfer the resident using a PAL lift without waiting for a second staff member, as required by the resident's care plan. Additionally, the CNA did not secure the leg straps, which are necessary for the resident's safety during the transfer. As a result, the resident fell from the lift, sustaining an abrasion to the right hip. The resident involved in the incident was dependent on staff for sit-to-stand transfers, as identified in their medical record and care plan. The care plan specifically required the assistance of two staff members and the use of a leg strap during transfers to ensure the resident's safety. The failure to adhere to these requirements not only resulted in the resident's fall and injury but also placed all residents transferred via a stand lift at risk for similar incidents.
Incomplete Medical Record for Resident Altercation
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident involved in a resident-to-resident altercation. The incident occurred when staff overheard elevated voices and intervened to find two residents attempting to take a walker from one another, although no physical contact was noted. The medical record of one of the residents involved, who has a diagnosis of Alzheimer's Disease, lacked documentation related to this incident. An administrative nurse confirmed the absence of documentation and expressed the expectation that such documentation should have been completed for both residents involved in the incident.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs regarding call lights for one resident with a soft touch call light. The resident, who had a history of falls and was at high risk for falls, was observed attempting to get out of bed without a call light within reach. After being assisted to the bathroom, the resident was transferred to a Broda chair and left alone in the room without a call light within reach. This was contrary to the facility's policy and the resident's care plan, which required the call light to be accessible at all times and the resident not to be left alone in the room without supervision. An administrative nurse confirmed that the facility's standard of care is to ensure every resident has their call light within reach.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one of the sampled residents. Specifically, the quarterly MDS for Resident #1 was incorrectly coded to indicate that the resident received an antipsychotic medication within the 7-day look-back period, despite the medical record lacking documentation to support this. This discrepancy was confirmed during an interview with the MDS coordinator, who acknowledged the miscoding error.
Failure to Update Care Plan for Resident Transfers
Penalty
Summary
The facility failed to review and revise the comprehensive care plan to reflect the current status of a resident, identified as Resident #227. The care plan initially indicated that the resident required a sit-to-stand lift for transfers, but it was later revised to require a full-body mechanical lift. Despite this revision, the NAR/CNA care plan was not updated, leading to the use of an incorrect transfer method by two CNAs. During an observation, the CNAs used a sit-to-stand lift, which was not suitable as the resident failed to bear weight and remained in a semi-seated position. An administrative nurse confirmed that the NAR/CNA care plan did not include the updated transfer information. This failure to update the care plan limited the staff's ability to communicate the resident's needs and ensure continuity of care. The facility's policy required that care plans be updated and changes made as they occur to ensure the most current care plan for the resident, but this was not followed in the case of Resident #227.
Failure to Prevent Accidents and Elopements
Penalty
Summary
The facility failed to ensure residents received adequate supervision and assistance to prevent accidents. Specifically, for one resident with chronic pain, weakness, and a history of falls with a hip fracture, the staff did not utilize the correct lift during transfers. Despite the care plan being updated to require a Hoyer lift for transfers, two CNAs used a sit-to-stand lift, causing the resident discomfort and pain. The CNAs were unaware of the care plan update, indicating a communication breakdown within the facility's staff regarding care plan changes. In another incident, the facility failed to provide appropriate supervision to prevent an elopement for a resident in the Memory Care Unit (MCU). The resident, who had severe cognitive impairment and a history of wandering, managed to elope from the unit on two separate occasions. During the first elopement, the resident was found outside the west door, and during the second, the resident made it off the premises. In both instances, the facility's staff failed to ensure adequate coverage and did not follow the protocol for monitoring and securing the resident. The first elopement occurred when one MCU staff member was on break, leaving only one staff member on the floor, who was not near the west door at the time. The second elopement happened because the door alarm did not sound on the pagers due to a failure to clear the pagers at shift change. Additionally, the CNA involved did not get a replacement to cover the floor during their break, further compromising the resident's safety. These incidents highlight significant lapses in supervision and adherence to protocols designed to prevent such occurrences.
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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.
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Nursing homes near Devils Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Lakota | 23.4 mi | ★★★★★ | 0 | 0 |
| Towner County Living Ctr | 31.1 mi | ★★★★★ | 8 | 0 |
| Lutheran Home Of The Good Shepherd | 33 mi | ★★★★★ | 3 | 0 |
| Nelson County Health System Care Center | 39 mi | ★★★★★ | 2 | 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.