Eventide Jamestown

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on information received from the complainant, review of facility policy and resident interviews, the facility failed to ensure reasonable accommodation of needs regarding call lights for 4 of 8 confidential residents (Residents C, D, E, and G. Failure to answer call lights timely, may result in discomfort, increased falls, and/or incontinence.Findings include:Review of the facility policy titled Standards of Care occurred on 08/26/25. This policy, revised August 2024, stated, . Staff will respond to call lights in a timely manner .-During an interview on 08/26/25 at 11:20 a.m., Resident D stated, I have my call light now but sometimes

they forget to give it to me. Sometimes it takes a half hour or longer for help. One time I waited on the toilet and had to yell for someone to come.-During an interview on 08/26/25 at 11:30 a.m., Resident E stated, A couple of months ago I had soiled myself in bed and needed to be changed. I waited for almost two hours.-During an interview on 08/26/25 at 11:55 a.m., Resident G stated, Staff run ragged around here and

they aren't very nice. One time I had my light on for over an hour and when they came in, I told them I wouldn't have had an accident [incontinent bowel movement] if they would have come sooner. The aide got mad at me for scolding her and walked out. I had to wait for someone to come back.During an interview on 08/26/25 at 5:29 p.m., an administrative staff member (#2) stated she expected staff to answer call lights within 5 minutes as that is her baseline for audits.

Residents Affected - Some

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eventide Jamestown

1300 2nd Pl NE Jamestown, ND 58401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, and confidential resident interviews, the facility failed to provide palatable and attractive food for 5 of 10 confidential residents (Residents B, D, F, G, and H). Failure to ensure residents receive food that is palatable, places residents at risk of weight loss and nutritional decline.Findings include:Review of the lunch menu served on 08/26/25 identified tater tot casserole (hotdish), tomato wedges, pacific blend vegetables, and a sundae brownie. -During an interview on 08/26/25 at 11:20 a.m., Resident D stated, They told me they didn't have anything for me [special diet], so I ordered plain mashed potatoes, but they covered them in gravy, so I didn't eat. -Observation on 08/26/25 at 11:45 a.m. showed a meal tray in Resident F's room. The plate contained two mounds of a brown substance (that did not resemble tater tot casserole) and the resident stated, This is supposed to be tater tot hotdish. The food is terrible. The dietitian gave me Ensure [a supplement] but I get tired of that but there's nothing else to eat.

The resident ate only the dessert.-Observation on 08/26/25 at 11:55 a.m. showed a meal tray in Resident G's room. The resident pointed to the tray and stated, It is disgusting. This is supposed to be hotdish, but it reminds me of liver sausage I had to eat growing up, but this is worse. One day we had soup that a dog wouldn't eat. The resident ate only the dessert.-During an interview on 08/26/25 at 12:10 p.m., Resident H identified staff warmed food from the resident's personal refrigerator per request for lunch and stated, I wasn't going to eat the stuff they were serving, it's terrible.-During an interview on 08/26/25 at 2:40 p.m., Resident B stated, the food seems to be of lesser quality. I can't eat it. They offer me something else but how many cheese sandwiches can you eat.Observation of the main dining room on 08/26/25 at 12:20 p.m. showed five separate plates with untouched hot dish left on the plates. During an interview on 08/26/25 at 4:35 p.m. an administrative staff member (#1) stated staff served the casserole with portion scoops which made the mounds on the plate.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet