Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Fair Meadow Nursing Home during CMS and state inspections, most recent first.
A resident with intact cognition and COPD was allowed to self-administer nebulized medications without a comprehensive assessment or care plan in place. An LPN prepared and left the medications for the resident to take independently, and staff interviews confirmed that no formal assessment or approval for self-administration had been completed, contrary to facility policy.
A resident was subjected to physical restraints that were not required for medical treatment, in violation of regulations mandating that residents remain free from unnecessary restraints.
A resident with moderate cognitive impairment and multiple mobility-related diagnoses was transferred from a wheelchair to a recliner by a nursing assistant without the use of a gait belt, contrary to the resident's care plan and facility policy. The nursing assistant lifted the resident by the torso, and interviews with an LPN and the DON confirmed that a gait belt is required for all assisted transfers. Facility policy also directs staff to use a gait belt for wheelchair transfers.
A resident with cognitive impairment and urinary issues had an indwelling catheter order that lacked specific type and size details. Staff relied on the care plan, not a physician order, for catheter specifications, resulting in the use of a catheter and balloon size not clearly ordered by a physician. The DON and NP confirmed that staff were expected to follow explicit physician orders, but this was not done, leading to inconsistent catheter care and documentation.
A resident with multiple chronic conditions did not consistently receive required routine physician visits every 60 days. An LPN responsible for scheduling visits used a handwritten schedule that was discarded after each visit, and could not account for the missed evaluations. The DON confirmed that staff were expected to track and report such lapses, but this was not done, resulting in noncompliance with facility policy.
A resident was administered medications in incorrect doses and given a medication not currently ordered, resulting in a medication error rate of 9.09%. An RN prepared two potassium tablets instead of one, one vitamin D3 tablet instead of two, and included oxybutynin, which was not ordered. The errors were only identified after a surveyor intervened, and the RN acknowledged not following proper medication administration procedures.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
Several residents with complex medical conditions did not have required physician progress notes documented during routine visits, despite the presence of signed order summaries. An LPN responsible for medical records provided verbal reminders to physicians about missing notes but did not document these reminders or formally report the issue to administration. The DON and administrator were not fully aware of the extent or duration of the missing documentation, which was not in compliance with facility policy requiring progress notes at each visit.
A resident with multiple fractures and osteoarthritis fell during a transfer with a mechanical stand device, resulting in a head injury and a hip fracture. The facility did not thoroughly investigate the incident, as required by policy, and failed to inspect the equipment or verify the cause of the fall. Interviews indicated potential issues with the harness and securing of the resident, but no follow-up was conducted.
The facility failed to educate three residents on immunizations per CDC guidance. One resident with a history of COVID-19 and another with chronic pulmonary edema had received previous pneumococcal vaccines but lacked documentation of education on boosters. A third resident with congestive heart failure had not been offered the PCV13 vaccine. Interviews revealed that the infection preventionist did not provide education on PCV20 unless asked, contrary to facility policy and CDC guidance.
A resident with severe cognitive impairment was subjected to continuous use of a seatbelt as a physical restraint without comprehensive reassessment or adherence to care plan interventions. Despite being a good candidate for restraint elimination, the facility failed to explore less restrictive alternatives or document the necessity and effectiveness of the restraint, leading to a deficiency.
A resident with moderate cognition and Parkinson's disease frequently used a golf cart for off-campus activities without a comprehensive assessment of their ability to safely operate it. The facility did not evaluate the resident's physical and cognitive abilities for safe golf cart use, and the care plan lacked relevant interventions. Staff assumed an assessment had been completed, but none was found in the medical record. The facility also lacked a policy on motorized golf cart use.
A resident with MRSA was not properly managed under contact precautions, as staff failed to consistently use PPE and adhere to hand hygiene protocols. Despite signage and policy guidelines, staff entered the resident's room without gowns or gloves and did not wash hands between glove changes during care. Interviews revealed a lack of awareness about the resident's infection and necessary precautions.
Failure to Assess and Care Plan for Self-Administration of Nebulized Medications
Penalty
Summary
The facility failed to comprehensively assess and care plan a resident's ability to self-administer nebulized medications. The resident, who had intact cognition and diagnoses including a circulatory disorder, aneurysm, and COPD, was observed receiving prepared nebulizer medication from an LPN, who then left the resident to self-administer the medication independently. The care plan for the resident included interventions for altered respiratory status and directed staff to administer medications as ordered, but did not include any evidence of an assessment or approval for the resident to self-administer nebulized medications. Interviews with staff revealed that the LPN assumed an assessment had been completed and routinely left multiple nebulized medications with the resident to self-administer during the night, checking back later to confirm administration. The RN responsible for assessments confirmed that no formal assessment or order for self-administration had been completed, as she was unaware the resident was independently administering the medications. The DON stated that facility policy required a self-administration assessment and care planning if a resident requested to self-administer medications, but this process had not been followed for the resident in question.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Use Gait Belt During Assisted Transfer
Penalty
Summary
A deficiency occurred when staff failed to implement required safety interventions during a transfer for a resident with moderate cognitive impairment and multiple diagnoses, including osteoporosis, osteoarthritis, muscle weakness, and low back pain. The resident's care plan specified that transfers should be performed with maximal assistance of one staff member and the use of a full wheeled walker and gait belt. During an observed transfer, a nursing assistant moved the resident from a wheelchair to a recliner without using a gait belt, instead lifting the resident by wrapping her arms around the resident's torso. The nursing assistant stated that she did not use a gait belt because the transfer was short and did not require steps. Interviews with facility staff, including an LPN and the DON, confirmed that the facility's policy requires the use of a gait belt for all assisted transfers, regardless of the distance. The DON acknowledged that not using a gait belt and lifting the resident by the torso could have caused injury or pain and that there would have been no secure way to assist the resident if she began to fall. Review of the facility's policy further confirmed that staff are directed to apply a gait belt for all wheelchair transfers.
Failure to Ensure Proper Physician Order and Catheter Specification
Penalty
Summary
The facility failed to ensure a proper physician order for an indwelling urinary catheter for a resident with obstructive and reflux uropathy, dementia, and benign prostatic hyperplasia. The physician order on file directed staff to change the Foley catheter every 90 days but did not specify the type or size of the catheter to be used. The resident's care plan indicated the use of a 16 French catheter with a 10 ml balloon, but this information was not reflected in the physician order. During care, staff referenced the care plan for catheter specifications rather than a physician order, and a registered nurse provided a stock 14 French catheter with a 30 ml balloon, stating she would only use 10 ml of saline in the balloon to match the care plan, not the actual balloon size. The director of nursing confirmed that staff were expected to follow physician orders and document all relevant details during catheter changes, but acknowledged that using a 30 ml balloon with only 10 ml of saline was not in accordance with the order. Interviews revealed that the nurse practitioner expected staff to have a specific order for a 16 French catheter with a 10 ml balloon and to follow it accordingly. The facility's policy on catheter-associated UTI prevention described the insertion procedure but did not address the requirement for a physician order specifying catheter type and size. The lack of a clear, specific physician order and reliance on the care plan for catheter details led to inconsistencies in catheter care and documentation for the resident.
Failure to Ensure Timely Routine Physician Visits
Penalty
Summary
The facility failed to ensure that a long-term resident received routine physician visits every 60 days as required. The resident, who was cognitively intact and had diagnoses including atrial fibrillation, major depressive disorder, morbid obesity, and lymphedema, did not consistently receive timely evaluations by a medical provider. Review of the medical record showed gaps in the timing of provider visits. During interviews, an LPN responsible for scheduling these visits could not explain the missed evaluations and stated that she maintained a handwritten schedule, which was discarded after each provider visit. The DON confirmed that staff were expected to track and ensure timely physician evaluations, and that this lapse should have been reported to administration. Facility policy required physician visits at least every 60 days after the first 90 days of admission, with a 10-day grace period, but this was not consistently followed for the resident in question.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
A medication error rate of 9.09% was identified during a survey observation of medication administration for one of seven residents. The registered nurse (RN) prepared medications for a resident, including potassium chloride and vitamin D3, but initially selected incorrect doses—two potassium tablets instead of one, and one vitamin D3 tablet instead of the ordered two. The error was identified only after the surveyor intervened and asked the RN to review the prepared medications. Additionally, the RN prepared and included oxybutynin, a medication not currently ordered for the resident, in the medication cup. The RN admitted she was working too quickly and was unsure if she would have caught the errors without the surveyor's intervention. The facility's policy required staff to compare the medication listed on the resident's Medication Administration Record (MAR) with the medication container label at three separate points and to follow the eight rights of medication administration. The RN did not adhere to these procedures, as evidenced by the preparation of incorrect doses and the inclusion of a medication not listed on the MAR. The director of nursing confirmed that staff are expected to closely check the MAR and medication bottles to prevent such errors.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive program but does not provide specific details about individual residents, staff actions, or particular infection control lapses observed during the survey.
Failure to Maintain Complete Physician Progress Notes in Medical Records
Penalty
Summary
The facility failed to maintain complete medical records by not ensuring that physician progress notes were written, signed, and dated during routine visits for four residents. Specifically, the medical records for these residents did not contain the required physician progress notes for their respective visits, despite having order summary reports signed by the physicians. The residents involved had various diagnoses, including atrial fibrillation, major depressive disorder, morbid obesity, lymphedema, cerebral palsy, epilepsy, Alzheimer's disease, type 2 diabetes, dementia, hypertension, insomnia, weakness, and osteoarthritis. The absence of these progress notes was identified through document review and interviews. During interviews, an LPN responsible for medical records explained that when physicians made rounds, she provided a list of residents needing evaluation and waited for the completed progress notes to be returned for scanning into the medical record. However, in some cases, such as when a physician resigned from their clinic, the notes were not entered into the record in a timely manner. The LPN stated that reminders to physicians about missing notes were given verbally but not documented, and the issue was not formally reported to administration. The administrator confirmed awareness of some missing documentation but was unaware of the extent or duration of the problem. Facility policy required physicians to review care and document progress notes at each visit, which was not consistently followed.
Failure to Investigate Fall from Mechanical Stand Device
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who experienced a fall during a staff-assisted transfer with a mechanical stand device. The resident, who had multiple fractures of the pelvis and osteoarthritis, was dependent on staff for transfers. An incident report indicated that the resident was found on the bathroom floor after slipping out of the harness strap during a transfer. The resident hit her head and was later diagnosed with a non-displaced fracture of the acetabulum. Despite the incident, the facility did not conduct a thorough investigation to determine the cause of the fall. Interviews revealed that the nursing assistant had used a medium-sized sling and leg straps during the transfer, but the director of nursing did not inspect the harness or the lift after the incident. The physical therapist suggested that improper securing of the resident's knees or harness could lead to a fall, but no inspection was conducted to verify these possibilities. The facility's policy required an internal investigation, including staff and resident interviews, but this was not adequately followed, leading to a deficiency in addressing the alleged neglect of care.
Failure to Provide Immunization Education per CDC Guidance
Penalty
Summary
The facility failed to provide education on immunizations per CDC guidance for three residents reviewed for immunizations. Resident 15, who had a history of COVID-19, received the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13) in previous years, but there was no evidence that they or their representative received education regarding a pneumococcal vaccine booster. Similarly, Resident 22, diagnosed with chronic pulmonary edema, had received both PPSV23 and PCV13, but their medical record lacked documentation of education about a pneumococcal vaccine booster. Resident 36, with congestive heart failure, had received PPSV23 but not PCV13, and there was no evidence of education or offering of the pneumococcal vaccine booster. Interviews with facility staff revealed that the infection preventionist, LPN-B, did not provide education about the PCV20 immunization unless specifically asked by the resident or their representative. The Director of Nursing acknowledged that residents or their representatives should have been educated about the PCV20 and that this should have been documented in the medical records. The facility's policy required education on the benefits and potential side effects of pneumococcal immunizations, aligning with CDC guidance that recommended shared clinical decision-making for administering PCV20 at least five years after the last pneumococcal vaccination.
Failure to Reassess and Appropriately Use Physical Restraints
Penalty
Summary
The facility failed to ensure a comprehensive reassessment was completed for a resident, R9, regarding the use of a seatbelt as a physical restraint. R9, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, was using a seatbelt in a tilt-in-place wheelchair daily. The care plan indicated the seatbelt was necessary for positioning due to R9's tendency to lean forward and reach for her feet, a behavior linked to her past as a seamstress. However, the facility did not adequately reassess the necessity of the restraint or explore less restrictive alternatives, despite R9 being identified as a good candidate for restraint elimination. Observations and interviews revealed that staff consistently failed to release R9's seatbelt according to care plan interventions. During meals and activities, when staff were present and could supervise R9, the seatbelt was not removed, contrary to the care plan's directives. Staff interviews indicated a lack of clarity and consistency in the application and removal of the seatbelt, with some staff stating it was always used, while others mentioned it was checked every 30 minutes and removed every two hours. Despite R9 exhibiting no agitation or behaviors while seated, the seatbelt remained fastened, indicating a failure to follow the care plan and facility policy. The facility's policy on restraint use emphasized that restraints should only be used for medical symptoms that cannot be addressed by less restrictive interventions. The policy required regular reassessment and documentation of the restraint's necessity and effectiveness. However, the documentation for R9 lacked detailed information on the frequency and necessity of the restraint, and there was no evidence of ongoing re-evaluation or attempts to reduce or eliminate the restraint. This oversight contributed to the deficiency, as the facility did not adhere to its own policies or federal regulations regarding restraint use.
Failure to Assess Resident's Safe Use of Golf Cart
Penalty
Summary
The facility failed to comprehensively assess and develop interventions for the safe use of a motorized golf cart by a resident with moderate cognition and Parkinson's disease. The resident, who had upper extremity impairment and was independent or needed supervision with activities of daily living, frequently left the facility independently using a golf cart. Despite the resident's regular use of the golf cart for off-campus activities, the facility did not conduct an assessment to evaluate the resident's physical and cognitive abilities for safe operation of the golf cart. Additionally, the resident's care plan lacked any focus, goals, or interventions related to the safe use of the golf cart. Interviews with staff revealed that while some staff members believed the resident was a safe driver, no formal assessment had been completed to confirm this. The social services designee and other staff members assumed that an assessment had been done but did not verify its existence in the resident's medical record. The assistant director of nursing confirmed that the facility had not assessed the resident's ability to safely operate the golf cart and had not implemented any interventions to ensure the resident's safe return after leaving the facility. Furthermore, the facility did not have a policy regarding the use of motorized golf carts.
Failure to Follow Infection Control Protocols for Resident with MRSA
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols for a resident diagnosed with a multi-drug resistant organism (MDRO), specifically methicillin-resistant Staphylococcus aureus (MRSA). The resident, who required extensive assistance with activities of daily living, was placed on contact precautions due to a boil-like area on her labia that tested positive for MRSA. Despite the presence of signage indicating the need for personal protective equipment (PPE) upon entering the resident's room, staff members were observed not following these precautions. For instance, a nursing assistant entered the resident's room without donning a gown or gloves and interacted with the resident, including providing a drink of water, before using hand sanitizer only after exiting the room. Further observations revealed additional lapses in infection control practices. During a care session, nursing assistants were seen not washing their hands between glove changes while attending to the resident's personal hygiene needs. One assistant removed gloves soiled with feces and continued to work with the resident without washing hands or applying new gloves. This lack of adherence to hand hygiene and PPE protocols was compounded by a lack of awareness among staff about the specific infection and the necessary precautions, as evidenced by interviews with nursing assistants who were unaware of the resident's MRSA diagnosis and the required contact precautions. Interviews with nursing staff, including a licensed practical nurse and a registered nurse, highlighted a communication gap regarding the resident's infection status and the necessary precautions. Staff were not adequately informed about the resident's MRSA infection or the rationale behind the contact precautions. Although the facility's infection prevention and control policy outlined the need for hand hygiene and PPE use, these guidelines were not consistently followed, leading to potential risks of infection transmission within the facility.
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Illustrative
What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fertile
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Care Community | 19.8 mi | ★★★★★ | 31 | 1 |
| Mcintosh Senior Living | 20 mi | ★★★★★ | 6 | 0 |
| Mahnomen Health Center | 20.7 mi | ★★★★★ | 11 | 0 |
| Villa St Vincent | 22.5 mi | ★★★★★ | 16 | 1 |
| First Care Living Center | 25.2 mi | ★★★★★ | 10 | 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.