Fargo Elim Health Care Center

Inspectors wrote1. Based on observation, record review, review of facility policies, and staff and hospice staff interviews, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 supplemental resident (Resident #62) with uncontrolled pain under hospice care. Failure of staff to effectively assess and treat Resident #62's pain resulted in unnecessary pain and discomfort.

Inspectors wroteBased on observation, record review, review of facility policies, confidential resident interviews, family, visitor and staff interview, the facility failed to provide necessary care in a manner that promotes, maintains, or enhances their quality of life for 16 of 35 sampled residents (Resident #67, A, B, D, E, F, G, H, I, J, L, M, N, O, P, and Q) requiring assistance with activities of daily living. Failure to assist dependent residents with toileting, answer call lights timely, and speak to residents in a dignified manner does not enhance the resident's quality of life and has the potential to affect the resident's psychosocial and personal dignity.

Inspectors wroteBased on observation, record review, review of facility policy, and family and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 5 of 20 sampled residents (Residents #5, #11, #27, #38, and #58) care plans reviewed. Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and resident and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 34 sampled residents (Resident #6 and #64). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interviews, the facility failed to provide appropriate toileting for 2 of 6 sampled residents (Resident #4 and #67) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, decreased self-esteem, urinary tract infections, and falls and/or injuries.

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to label medications in accordance with professional standards for 1 of 1 sampled resident (#46) observed for eye drop administration. Failure to ensure appropriate labeling of medications placed resident(s) at risk for medication errors.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen. Failure to ensure cleanliness of the ventilation system above the grill and removal of ice buildup in the walk-in freezer has the potential for contamination of food and may result in a foodborne illness. Findings Include: Review of the facility policy titled Food service areas shall be maintained in a clean and sanitary manner occurred on 03/12/26. This policy, dated 01/09/26, stated . Kitchen . surfaces not in contact with food shall be cleaned . enough to prevent the accumulation of grime. The initial observation of the kitchen, occurred on 03/09/26 at 12:35 p.m. with two dietary supervisors (#18 and #19) and showed the following: * An accumulation of grease and grime on the ventilation system above the grill. [...]

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 8 sampled residents (Resident #64 and #86) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), catheters, glove use, and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is prepared in accordance with professional standards for food service sanitation in 1 of 1 kitchen. Failure to prepare food in a sanitary manner, such as not wearing beard restraints, may result in contamination of food served to residents, staff, and visitors.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 19 sampled residents (Resident #2, #19, and #40). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to assess a resident for self-administration of medications for 1 of 2 sampled residents (Resident #29) observed with medications at bedside. Failure to evaluate the resident's ability to safely self-administer medications may result in medication errors and/or harm to the resident.

Inspectors wroteThis citation is considered past non-compliance based on review of the corrective action implemented by the facility immediately following the incident. Based on information from the complainant, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to promptly notify the physician to maintain the resident's highest level of well-being for 1 of 5 sampled residents (Resident #1) transferred to the emergency room (ER) for a change in health status. Failure to notify a provider of a residents change in condition and implement provider orders timely may have resulted in worsening respiratory symptoms and a delay in treatment.

Inspectors wroteThis citation is considered past noncompliance based on review of the corrective action implemented by the facility immediately following the incident. Based on information from the complainant, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 5 sampled residents (Resident #23) transferred to the emergency room (ER) for a change in health status. Failure to implement provider orders timely may have resulted in worsening respiratory symptoms and a delay in treatment.

Inspectors wroteBased on observation, record review, review of the facility policy, and staff interview, the facility failed to ensure staff followed infection control practices for 3 of 18 sampled residents (Resident #7, #15, #47) observed during cares. Failure to follow infection control practices related to catheter cares, wound care, and wearing proper personal protective equipment (PPE) has the potential for the transmission of communicable diseases and infections to residents and staff.