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 Eventide Fargo during CMS and state inspections, most recent first.
Infection control practices were not followed during resident care for multiple residents. CNAs failed to perform hand hygiene after removing soiled gloves and before applying clean gloves or touching other surfaces, did not wear gown and gloves during EBP personal care, and did not clean a urine spill on the floor. The observations involved incontinent care, catheter care, transfers, and dressing assistance, and included a resident on EBP related to sutures and residents with catheters in place.
MDS coding was inaccurate for two residents. One resident had hospice services, a terminal illness, and unstageable wounds with eschar, but the MDS did not code a prognosis of less than 6 months or the unstageable pressure ulcer. Another resident had an order for venlafaxine for depression/anxiety, but the significant change MDS did not code the antidepressant.
Failure to assess a resident's hemodialysis vascular access site twice daily. A resident with ESRD and a Permacath had a care plan and facility policy requiring ongoing monitoring of the access site, but the record lacked BID assessment documentation. Nursing notes later showed dialysis complications including a clot to the dialysis cath, the cath blowing during dialysis, and eventual Permacath replacement.
Incorrect medication labels were observed for two residents during med pass. One resident's Norvasc container still listed an old dose that did not match the current MAR, and another resident's Novolog insulin pen also showed an outdated dose. In both cases, the labels lacked a "refer to MAR" sticker, and the nurses confirmed the labels were incorrect and that a new label had not been ordered.
The facility failed to accurately code the MDS for two residents regarding medication administration. One resident's MDS did not reflect the use of an antiplatelet medication, while another's incorrectly indicated the use of a diuretic. An administrative staff member confirmed these coding errors.
The facility did not follow professional standards for insulin administration for two residents and one supplemental resident. Nurses failed to clean insulin pens with alcohol before attaching new needles and did not prime the pens correctly, which could lead to infections or incorrect dosing.
The facility failed to ensure that the medical records of two residents receiving hospice services contained necessary documentation, including the hospice election form, plan of care, and certification of terminal illness. This deficiency was identified during a survey through record reviews and staff interviews, with an administrative nurse confirming the absence of these documents.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards during resident care, including bodily fluid cleanup, hand hygiene, and enhanced barrier precautions (EBP), for 4 of 12 sampled residents. Facility policies reviewed on 09/18/25 stated that body fluids must be cleaned and disinfected with an appropriate disinfectant and that staff must use gowns and gloves during high-contact resident care activities under EBP, including hygiene, changing briefs, and assisting with toileting. For Resident #45, the record showed EBP related to sutures. During incontinent care, a CNA provided care, applied a clean brief, and then removed soiled gloves, applied new gloves, cleaned bowel movement and urine from the toilet, and removed the soiled gloves. Without performing hand hygiene, the CNA removed the gait belt and transported the resident to the dining room. On another observation, a CNA provided perineal care without wearing a gown or gloves. A nurse confirmed staff were expected to perform hand hygiene before and after glove changes and to wear a gown and gloves during personal cares for residents on EBP. For Resident #3, two CNAs transferred the resident from a wheelchair to bed with a full-body mechanical lift, removed wet pants and brief, and noted the wheelchair cushion was visibly soiled with urine. One CNA provided perineal care and handed soiled wipes to the other CNA to discard. Both CNAs removed soiled gloves and, without performing hand hygiene, pulled up clean pants and placed the lift sling under the resident before completing hand hygiene. For Resident #17, the record showed a catheter in place and a prior note that family voiced concerns about the catheter bag often leaking. During observation, a CNA emptied the catheter bag, urine spilled on the floor, and the CNA failed to clean the spill. The CNA also removed soiled gloves and, at several points, did not perform hand hygiene before touching other surfaces, before applying clean gloves, or before continuing resident care. For Resident #13, the record showed a catheter in place, and during observation a CNA emptied the catheter bag, removed gloves, and without performing hand hygiene applied a new pair of gloves to dress the resident. An administrative nurse confirmed staff were expected to perform hand hygiene after removing gloves, before applying clean gloves, and to clean the floor after a urine spill.
MDS Coding Errors for Prognosis, Pressure Ulcer, and Antidepressant Use
Penalty
Summary
Accurate MDS coding was not completed for 2 of 22 sampled residents. For one resident, record review and staff interview showed a terminal illness, hospice services beginning on 05/22/25, and unstageable wounds to the right heel and great toe. A wound care flow sheet dated 07/23/25 documented the right heel as 3 cm x 2.7 cm x 0 cm unstageable and the right great toe as 0.6 cm x 0.6 cm x 0 cm unstageable with eschar, but the quarterly MDS failed to identify a prognosis of life expectancy less than 6 months and failed to code the unstageable pressure ulcer. An MDS nurse agreed staff failed to code life expectancy of less than six months and an unstageable pressure ulcer. For another resident, the medical record included a physician order for venlafaxine, an antidepressant, given one time a day for depression/anxiety. The significant change MDS failed to identify that the resident received an antidepressant. During interview, the MDS nurse stated, "I must have just missed it" when referring to coding venlafaxine.
Failure to Assess Hemodialysis Vascular Access Site
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for one sampled resident who required hemodialysis and had a Permacath vascular access. The resident had a diagnosis of ESRD, and the care plan directed staff to monitor circulation, motion, and sensation of the extremity with the access site per facility policy and to update the provider/dialysis center if concerns were noted. The facility policy titled "Hemodialysis Access Sites" required ongoing monitoring and care of the resident's vascular access and directed staff to assess the central venous access site twice daily for redness, warmth, and drainage. Record review showed nursing documentation on one date stating the resident was no longer using a fistula and was utilizing a port to the right upper chest with dressing in place and no obvious bruising, bleeding, redness, or drainage. Later notes documented that the resident returned from dialysis early because she reported a clot to her dialysis cath and would need it replaced, that her Perma Cath blew during dialysis, and that the Perma Cath was replaced. During interview, a nurse manager confirmed the medical record lacked documentation of assessment of the resident's vascular access site twice a day.
Incorrect Medication Labeling for Two Residents
Penalty
Summary
The facility failed to ensure accurate labeling of medications for two supplemental residents during medication administration. Review of the facility policy stated that medications are to be labeled according to accepted pharmacy standards and that multi-dose vials must be labeled when opened. The contracted pharmacy guidelines stated that when a medication direction changes, the facility will place a "refer to MAR" sticker on the existing medication and pharmacy will supply a new and correct label. During observation, a nurse removed a Norvasc 5 mg container for one resident that still read "take 2 tablets daily," even though the current physician order and MAR showed the dose had changed to 1 tablet daily. The container did not have a "refer to MAR" sticker, and the nurse confirmed the label was incorrect and that staff had failed to order a new label. In a separate observation, a nurse removed a Novolog insulin pen for another resident that was labeled for 10 units SQ TID before meals, while the current physician order and MAR directed 8 units SQ TID before meals. The insulin pen also lacked a "refer to MAR" sticker, and the nurse confirmed the label was incorrect and that staff had failed to order a new label. An administrative nurse stated staff were expected to follow facility policy and ensure medications had a "refer to MAR" sticker or a correct dose label.
Inaccurate MDS Coding for Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which is essential for reflecting their current status and needs. For one resident, the medical record indicated a physician's order for Aspirin, an antiplatelet medication, but the quarterly MDS did not reflect this. For another resident, the MDS was incorrectly coded to show that the resident received a diuretic medication during the 7-day look-back period, despite the medical record lacking documentation of such administration. An administrative staff member confirmed the inaccuracies in coding during an interview.
Failure to Follow Insulin Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice in the preparation and administration of insulin for two sampled residents and one supplemental resident. Observations revealed that a nurse did not clean the end of the insulin pens with alcohol before attaching new needles for Residents #28 and #51. This step is crucial to prevent potential infections and ensure the accurate administration of insulin doses. Additionally, another nurse was observed preparing insulin pens for Resident #47 without cleaning the ends with alcohol and priming the pens in a horizontal position, contrary to the facility's policy which requires priming with the pen in a vertical position. These actions were inconsistent with both the facility's policy and professional guidelines, which emphasize the importance of cleaning the pen and proper priming technique to ensure safe and effective insulin administration.
Deficiency in Hospice Documentation for Residents
Penalty
Summary
The facility failed to ensure that the medical records of two residents receiving hospice services contained the necessary documentation, including the hospice election form, the most recent hospice plan of care, and the certification of terminal illness. This deficiency was identified during a survey through record reviews and staff interviews. The hospice contract, signed on 01/30/20, outlined the requirement for the facility to obtain these documents from the hospice agency to ensure proper coordination of care. Resident #4, who elected hospice services on 03/13/24 prior to admission, had a medical record that lacked the hospice election form and certification of terminal illness. Similarly, Resident #83, who elected hospice services on 04/12/24 for conditions including congestive heart failure and hypertension, had a medical record missing the hospice election form, plan of care, and certification of terminal illness. An administrative nurse confirmed the absence of these required documents in the residents' medical records during an interview conducted on 08/28/24.
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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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Nursing homes near Fargo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sheyenne Crossings Care Center/tcu | 1.5 mi | ★★★★★ | 3 | 0 |
| Smp Health - St Catherine South | 3.4 mi | ★★★★★ | 0 | 0 |
| The Meadows On University | 3.5 mi | ★★★★★ | 2 | 0 |
| Bethany On University | 3.7 mi | ★★★★★ | 3 | 0 |
| Fargo Elim Health Care Center | 3.8 mi | ★★★★★ | 8 | 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.