Fargo Elim Health Care Center

Based 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. Findings include: Review of the facility policy titled Resident dignity, choices and preferences occurred on 03/12/26. This policy, dated 11/20/25, stated, . It is the expectation that all . employees will treat residents with dignity and respect at all times. Residents will be encouraged to voice their concerns and needs at all times to ensure their care needs, choices and preferences are honored. Review of the facility policy titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility policy titled Care plan and baseline care plan occurred on 03/11/26. This policy, dated 02/18/26, stated, . Care plans are update with MDS [Minimum Data Set]/care conference schedule and as needed to assure that they are an accurate reflection of the resident and their care needs. - Review of Resident #5's medical record occurred on all days of survey. Physician's orders included spironolactone (a diuretic) once a day for chronic combined systolic and diastolic heart failure. A quarterly MDS, dated [DATE], identified diuretics as a high-risk drug/medication. The care plan lacked a problem,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:SECTION I: ACTIVE DIAGNOSESThe Long-Term Care Facility RAI User's Manual, revised October 2025, pages I-9 and I-12, stated, . Active Diagnoses . Coding Instructions: Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status . mood or behavior status, medical treatments, nursing monitoring. during the 7-day look-back period . Psychiatric/Mood Disorder . I6100, post-traumatic stress disorder (PTSD) . -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include:Review of the facility policy titled Nursing assistant standard care occurred on 03/12/26. This policy, dated 02/18/26, stated, . Assist with toileting needs per resident request. Refer to care plan for individualized toileting needs.- Review of Resident #67's medical record occurred on all days of survey. Diagnosis included fecal urgency. The current care plan stated, . COGNITION-strength: [Resident #67's name] does not have any cognitive diagnoses. He is alert and oriented and is able to make needs known to staff. TOILETING: Staff to provide assist x2 [assistance of two staff] with toileting. Per resident he has no control of bowels. Offer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 834, stated, . administer the drug. Read the MAR [medication administration record] carefully and perform three checks with the labeled medications. Box 35.5 Check Three Times for Safe Medication Administration . First Check . Read the MAR and remove the medication(s) from the client's drawer. Verify that the client's name and room number match the MAR. Compare the label of the medication against the MAR. Second Check While preparing the medication . look at the medication label and check against the MAR. Third Check Recheck the label on the container . against the MAR .Observation on 03/11/26 at 1:03…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. * An accumulation of ice/condensation on the ceiling above and beside the fan of the walk-in freezer and an accumulation of ice on boxes of food under the fan.During interviews on the afternoon of 03/09/26 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility policy titled Transmission-based precautions, enhanced barrier precautions and empiric precautions occurred on 03/12/26. This policy, dated 09/29/25, stated, . Residents with an indwelling medical device, even if the resident is not known to be infected or colonized with an MDRO [multi-drug resistant organism] . Examples of high contact resident care activities requiring gown and glove use for enhanced barrier precautions include . Device care . urinary catheter . Review of the facility policy titled Hand Hygiene occurred on 03/12/26. This policy, dated 07/02/25, stated, . Hand washing/sanitizing is necessary . 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility policy titled; Food and Nutrition Services occurred on 02/20/25. This policy, revised 01/12/24 stated, . Hairnets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. The 2022 Food and Drug Administration (FDA) Food Code, Chapter 2, pages 21-22 states, . 2-402 Hair restraints . (A) . FOOD EMPLOYEES shall wear hair restraints such as . beard restraints . to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Observation of the kitchen during the initial tour on 02/18/25 at 12:53…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2024, pages N-6 to N-8, stated, . Code all high-risk drug class medications according to their pharmacological classification . N0415: High-Risk Drug Classes: Use and Indication . N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period . N0415E1. Anticoagulant: Check if an anticoagulant medication was taken by the resident at any time during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the policy titled, Self administration of medication occurred on 12/19/23. This policy, last reviewed February 2023, stated, . Upon admission and PRN [as needed], the licensed nursing staff informs every resident of his/her rights to self-administer medications and explains the self-administration of medication program. If the resident wishes to self-administer medications, complete the applicable observation/assessment in the EHR [electronic health record]. If the nurse determines through this assessment that the resident is able to self-administer medications . Obtain an order from the provider that the resident may self-administer medications. Review of Resident #29's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This 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. Findings include: Review of the facility policy titled Change in condition occurred on 12/20/23. This policy, revised May 2022, stated, . The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) . significant change in the resident's physical/emotional/mental condition . notifications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This 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. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Massachusetts, page 63, stated, .Carrying Out a Physician's Orders. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. The nurse is considered responsible for notifying the primary care provider of any significant changes in the client's condition, whether the primary care provider…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility policy titled Transmission based precautions and enhanced barrier precautions [EBP] occurred on 12/20/23. This policy, revised May 2023 stated, . use enhanced barrier precautions . use enhanced barrier precaution sign . during high contact resident cares requiring gown and glove use . goal is to keep our skin/uniform from touching the resident during high contact activities so that we can avoid potential transfer of organisms to other residents . examples include . urinary catheter care . peri-care . changing briefs or assisting with to toileting . wound care . Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.