Fargo Health Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to prevent a resident from being physically assaulted by another resident. This failure affected one resident (R1) of three residents reviewed for physical abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident (R2) remains free from verbal and physical abuse/assault and free from injury (fracture) from another resident (R3) and failed to follow their abuse policy. These failures caused physical harm to R2, having a fracture and the need for emergency treatment and surgical intervention (sutures). These failures affected one resident (R2) out of three residents reviewed for verbal and physical abuse/assault.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an involuntary discharge was not based on the residents' condition at the time of transfer to acute care and failed to provide physician's documentation of the reasons a resident was involuntarily discharged from the facility in the resident's medical record. These deficient practices affected two of three residents (R1 and R4) reviewed for involuntary discharge. 1. R1 was admitted to the facility on [DATE] and was discharged to the hospital on 9/28/2025 and was not allowed to return to the facility. R1 was petitioned for involuntary discharge and was also served a 30-day notice for involuntary transfer and discharge. Progress notes dated 9/28/2025 2:39 a.m. document R1 stated am depressed because my sister died and want to go to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement care plan for psychosocial and mental well being and failed to provide the necessary services for the behavioral health needs of a resident. This applies to one (R1) of 4 residents reviewed for behaviors. As a result, R1 harmed self requiring psychiatric hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents environment was free from accident hazards. This failure affected 2 (R1 and R9) residents reviewed for accident hazards in the total sample of 9 residents. This failure resulted in R1 having access to scissors and used the scissors to cut her wrist and received 2 stitches as treatment.

Inspectors wroteBased on observation, interviews and review of records the facility failed to provide admission contract/agreement packets in a timely manner to 5 out of 5 residents (R1, R6, R7, R8 and R9).

Inspectors wroteBased on observation, interview, and record review the facility failed to follow menus, spreadsheets, and recipes. These failures have the potential to affect all 93 residents receiving food prepared in the facility's kitchen. Findings Include:On 08/12/2025 at 11:52 AM, R63 said, I don't get enough to eat and I'm always hungry. On 08/12/2025 at 12:22 PM, observed R63 eating lunch in unit dining room. R63 received ground turkey with gravy, sweet potato, peas, yellow cake, and juice. R63 did not received any bread or a substitution for bread. On 08/12/2025 at 12:30 PM, observed R7's lunch tray. R7 received turkey, sweet potatoes, peas, cake, nectar thick water and juice. R7 did not received any bread or substitution for bread. On 08/12/2025 at 12:45 PM, observed R21's lunch tray. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to a.) ensure kitchen staff wearing appropriate hair covering; b.) food items were properly labeled and dated; c.) food items stored according to manufacturer's guidelines. These failures have the potential to affect all 93 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to practice infection control and prevention measures to ensure staff wore appropriate personal protective equipment (PPE) for one (R5) resident on enhanced barrier precautions and appropriately handle and transport linen to prevent potential contamination. The facility also failed to track and register to report possible XDROs (Extensively Drug-Resistant Organisms) to the registry. These failures have the potential to affect all 93 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a medication error rate of less than 5% for 4 (R2, R34, R56, R60) of 4 residents with 9 errors for 30 medication administration opportunities. This resulted in a medication error rate of 30%.

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) properly date opened multi-dose inhaler for 2 (R18, R103) residents, (b) ensure that house stock medication (multidose Tubersol solution) was stored properly at appropriate temperature from 2 of 3 medication carts and 2 of 3 medication rooms inspected for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) ensure the rights of the resident to receive effective and accessible means of communication and b.) ensure the residents were treated with respect and dignity by not passing out meals to residents sitting together at the same time. These failures affected two residents (R55 and R59) in a total sample of 19 residents reviewed for resident rights.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure splints were applied as ordered by physician for 2 (R6 and R78) of 3 residents reviewed for limited range of motion in a sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to (a) ensure cigarette was kept safely to prevent an avoidable accident from occurring in the resident's environment for one (R55) of one resident reviewed for smoking, and (b) monitor and follow-up with a resident (R102) who went out on independent community pass for one of two records reviewed for discharge in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative toileting program to maintain bladder functioning for one (R2) resident in a total sample of 19 residents reviewed for bowel and bladder continence.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nebulizer mask and tubing were properly stored for one (R55) of one resident reviewed for respiratory care in a sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' rights to be free from physical and verbal abuse by other residents. This failure affected 3 (R1, R3, and R5) residents out of 7 residents reviewed for resident to resident abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure initial reportable for allegation of verbal abuse was reported within the mandated timeframe. This failure affected 1 (R5) resident reviewed for reporting of abuse in the total sample of 7 residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that one resident (R2) was free from abuse from her roommate (R3). This failure resulted in R2 being struck by R3 and sustaining a broken nose.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident (R3) was free from physical abuse. This failure resulted in R3 sustaining a bruise and skin tear to the left arm that required a dressing twice a day and R3 being afraid at the facility.

Inspectors wroteBased on interview, and record review the facility failed to submit the final investigation of an alleged abuse to IDPH (Illinois Department of Public Health) within 5 days of the alleged allegation. This failure affected two residents (R1 and R2) reviewed for resident-to-resident abuse. Findings Include: A facility reported incident was sent to IDPH (Illinois Department of Public Health) on 11/1/24. The reportable offenses documented on the Immediate Incident Investigation Report had check marks by physical, verbal, or mental abuse. Circumstances of alleged incident: On 11/1/24, R1 reported that earlier in the day he (R1) and co-resident (R2) allegedly engaged in a verbal and physical altercation. Both residents were separated immediately. No injuries were noted. On (11/1/24) IDPH was notified of the (11/1/24) incident involving R1 & R2 however a final report was not received. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the residents' right to be free from physical abuse for 3 (R5, R2, and R3) of 4 residents reviewed for abuse. These failures resulted in R5, getting hit on the top of the head by V9 (Certified Nurse Assistant/CNA), as well as R2 and R3 engaging in a verbal and physical altercation while unsupervised that resulted in injuries (scratch wounds). This failure resulted in R5, who is cognitively impaired, as a reasonable person that would not expect to be harmed in their own home or health care facility, causing them to feel fear, anxiety, and anger.

Inspectors wroteBased on interview and record review, the facility failed to prevent a resident's fall from the bed to the floor, who was assessed as a two person assist for bed mobility. This failure affected 1 (R44) of 28 residents reviewed for falls. R44 was emergently transferred to the hospital with increased pain and experiences psychosocial harm, feeling scared and afraid while being turned in bed by staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents' food items in the facility kitchen are dated when received and when opened; failed to discard expired food items; failed to follow proper food storage practices and labeling food to prevent food-borne illnesses; and failed to ensure that staff store their drinks out of the facility kitchen used for residents. These failures have the potential to affect all 94 residents receiving an oral diet in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents' call light device was within a residents reach to call for staff assistance which affected 4 residents (R37, R54, R56, R245) in the sample of 28 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a Psychiatric Rehabilitation Services Coordinator (PRSC) to meet the individualized psychosocial and mental health needs of residents. This failure has the potential to affect all 68 residents with diagnoses of Severe Mental Illness and other residents in the facility who require psychosocial support.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate person-centered and individualized psychosocial and mental health services to meet residents' needs. This affected 5 of 5 residents (R65, R79, R86, R88, and R195) reviewed for individualized psychosocial needs and interventions from social services staff, as stated in the care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the air-conditioner in a resident's room was working, failed to repair a broken wall heat vent cover, and failed to clean and cover the air-conditioner air filter in residents' rooms. These failures have the potential to affect 7 residents (R73, R84, R81, R89, R86, R65, R82) in a total of 28 residents reviewed for environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there is a code status documented under the physicians order in a resident's electronic medical record (EMR) which affected one resident (R11) in a sample of 28 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and functional environment for two residents (R9 and R13) in the sample of 28 residents reviewed for homelike environment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents receive assistance with shaving facial hair. This failure has affected one (R12) of six residents reviewed for personal hygiene and care.

Inspectors wroteBased on interviews and review of records, the facility failed to protect the residents' right to be free from physical abuse by resident (R2) against another resident (R1). The facility failed to follow their abuse policy by not having preventative measures in place for a resident with a history of physical, verbal, and sexually inappropriate behavior. The facility failed to have preventative measures in residents (R1) care plan before and after a resident (R1) was physically abused. These failures led to a resident (R2) physically assaulting another resident (R1) causing multiple injuries.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to have an effective pest control program and failed to monitor and log pest issues related to the presence of cockroaches in the kitchen. These failures have the potential to affect all 98 residents' food preparation and consumption due to presence of cockroaches in the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that cigarettes and loose pills were not stored in medication carts and failed to ensure that the basement medication storage room was free of clutter and expired medications. These failures have the potential to affect all 89 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to document the temperature on the temperature log for two freezers located in the kitchen area. This failure has the potential to affect all 89 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the trash bags in a trash dumpster and ensure that the dumpsters were always closed. These failures have the potential to affect all 89 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the second-floor bathroom wall tiles in good repair, failed to repair the peeling paint in the second-floor dayroom, and failed to keep the heating vent in the day room in good repair. These failures have the potential to affect all 33 residents on the second floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the protocol for medication administration by not checking all medications against the MAR (Medication Administration Record) during preparation of medications for two residents (R36 and R71) out of 5 residents reviewed for medication administration in the total sample of 28 Residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist one resident (R1) with nail care out of 6 residents reviewed for ADL (Activities of Daily Living) care in the total sample of 28 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who depends on staff's assistance for ADL (Activities of Daily Living) care gets help with shaving. This affects one resident (R41) reviewed for ADL care and grooming, in a total sample of 28 residents.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that a water flush order was followed for one resident (R63), who depends on g- tube for nutrition and hydration, out of 6 residents reviewed for quality care in the total sample of 28 Residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that oxygen tubing was contained when not in use for one resident (R37) on PRN (as needed) oxygen therapy out of 6 residents reviewed for infection control related to oxygen use in the total sample of 28 residents.