Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Fargo Elim Health Care Center during CMS and state inspections, most recent first.
Uncontrolled pain, insulin timing, and wheelchair positioning failures: A resident on hospice with CHF had repeated moaning, restlessness, and grunting while PRN opioid and anxiolytic use was delayed and inconsistent despite hospice staff urging more timely administration. Another resident received rapid-acting insulin well before the meal tray arrived, and a third resident with Parkinson’s disease and dementia was repeatedly observed leaning forward and to one side in a Broda chair with no clear head-positioning intervention in the care plan.
A facility failed to provide dignified, timely assistance with toileting and call lights for multiple residents who needed ADL help. Residents reported night CNA staff were rude, used disrespectful language, delayed or ignored call lights, left residents on the toilet too long, and sometimes refused toileting help, while one resident’s care plan required assist x2 with toileting and regular toileting offers. An observation also showed a CNA speaking in a raised voice during care.
Care plans were not reviewed and revised to match current resident status for several residents. One resident on a diuretic, one with a suprapubic catheter, one with a smoking safety discrepancy, one with a possible elopement/wanderguard issue, and one whose hearing amplifiers were no longer being used all had care plans that did not accurately reflect their current needs or conditions.
The facility failed to accurately code the MDS for two residents. One resident’s quarterly MDS listed PTSD as an active dx even though the resident denied ever having that diagnosis and the record lacked supporting documentation, while another resident’s admission MDS failed to code an ileostomy despite the resident confirming it and the care plan noting the bowel alteration.
Failure to provide timely toileting assistance for two residents. One resident with fecal urgency and a care plan for assist x2 and toileting on arising, after meals, before bed, and PRN reported that night staff ignored call light requests, told him to wait, and left him incontinent; the toileting log showed repeated gaps of 5 to 16 hours. Another resident whose care plan called for toileting in the AM, after meals, HS, and PRN said staff sometimes took a long time or did not come at all, and the toileting record showed repeated gaps of 4 to 24 hours.
Medication labeling was not maintained for a resident's eye drops when an MA removed a bottle from the med cart drawer and administered it even though the bottle only identified a room number and lacked the resident's name and administration instructions. An administrative nurse confirmed that all medications should have labels.
Kitchen Sanitation and Freezer Maintenance Deficiencies: Surveyors observed grease and grime buildup on the ventilation system above the grill and ice/condensation on the walk-in freezer ceiling and on boxes of food stored under the fan. Two dietary supervisors stated the vents and freezer ceiling were not on a regular cleaning schedule and were cleaned as needed.
Infection control and prevention standards were not followed for two residents on EBP for indwelling devices. A nurse caring for a resident with an ileostomy and indwelling catheter removed dressings and reapplied gloves twice without hand hygiene, while also handling a pen from a uniform pocket during care. A CNA caring for a resident with an indwelling catheter drained the catheter bag and then transported the resident in the same soiled gloves without removing them or performing hand hygiene. Facility policy required hand hygiene before and after care, after glove removal, and after handling catheters or urine.
Two male cooks were observed preparing food without wearing beard restraints, contrary to facility policy and FDA Food Code requirements. The facility's policy mandates the use of hairnets, caps, and beard restraints to prevent hair from contacting exposed food and clean equipment. An administrative staff member stated that new hires are told to keep facial hair trimmed, but there was no evidence of enforcement regarding beard restraint use.
Surveyors found that three residents' MDS assessments were inaccurately coded regarding high-risk medications. One resident's antibiotic and another's antidepressant were omitted from their MDS, while a third resident was incorrectly coded as receiving both an antiplatelet and an anticoagulant, despite only receiving an antiplatelet. Administrative staff confirmed these errors during the survey.
Uncontrolled pain, insulin timing, and wheelchair positioning failures
Penalty
Summary
The facility failed to provide necessary care and services to a resident on hospice with uncontrolled pain. Resident #62 had diagnoses including hypertensive heart disease with congestive heart failure and was admitted to hospice. The resident’s care plan directed staff to monitor comfort and medicate per orders, and physician orders included scheduled and PRN hydromorphone and lorazepam. The record and observations showed the resident was moaning, restless, grunting, and fidgeting, with family and hospice staff expressing concern that pain was not being assessed regularly and PRN pain medication was not being given in a timely manner. Facility documentation showed PRN hydromorphone and lorazepam were administered intermittently, with the last PRN hydromorphone given at 1:10 a.m. on 03/12/26 and the last PRN lorazepam given at 5:21 p.m. on 03/11/26. During observation on 03/12/26, the resident was leaning to one side, using accessory muscles to breathe, moaning, grunting, and calling for help until a nurse entered and administered scheduled hydromorphone, lasix, and lorazepam; the resident then appeared comfortable within minutes. Hospice notes documented repeated encouragement to facility staff to use PRN hydromorphone and lorazepam for nonverbal signs of pain and restlessness, and hospice staff stated the facility should use PRN medications more frequently and timely. The facility also failed to follow professional standards during insulin administration for another resident. Resident #27 received Fiasp insulin at 5:00 p.m., but the meal tray was not provided until 6:15 p.m., which was outside the manufacturer’s instruction to inject at the start of a meal or within 20 minutes after starting a meal. The nurse acknowledged the meal was not available at the time of insulin administration and stated a snack or juice was not offered. In addition, the facility failed to ensure proper wheelchair positioning for Resident #58, who had Parkinson’s disease, dementia with behavioral disturbance, osteoarthritis, pain, and restlessness/agitation. Observations showed the resident seated in a Broda chair leaning forward and to the right, while the care plan did not include interventions for proper head positioning and staff described using a blanket for head support that frequently fell out of place.
Failure to Provide Dignified, Timely Assistance With Toileting and Call Lights
Penalty
Summary
The facility failed to provide necessary care in a manner that promotes, maintains, or enhances residents’ quality of life for 16 of 35 sampled residents who required assistance with ADLs. The deficiency centered on failure to assist dependent residents with toileting, delayed or absent responses to call lights, and staff speaking to residents in a manner that was not dignified. The report states that these actions and inactions affected residents’ psychosocial and personal dignity. Resident #67’s record showed a care plan for assist x2 with toileting and toileting offers upon arising, after meals, before bed, and as requested. Resident #67 reported that at night staff did not come when the call light was used, that the call light was turned off at the nurses’ station, and that he had wet and soiled himself because help did not arrive. He also reported that a night CNA told him he had to wait to use the bathroom because it was not his time, then turned off the call light and left. During observation, two CNAs assisted Resident #67 with evening care and toileting, and one CNA told him to lock his wheelchair brakes, then stated, "He can lock it," and later raised her voice and told him, "SIT." Other residents and a visitor described similar concerns with night shift care. Residents reported rude, disrespectful, or rough treatment, call lights not being answered for long periods or not at all, being left on the toilet for extended periods, being told to use a bedpan when toileting was difficult, and staff speaking in another language and laughing during care. One resident reported needing to manage catheter care independently because staff were rude and slow to answer the call light. Another resident’s family member stated staff were not friendly, did not answer the call button at night, and left the resident on the toilet for long periods. An administrative staff member stated the expectation was that residents be treated with respect and dignity, like family.
Care plans not updated to reflect residents’ current status
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of 5 of 20 sampled residents. Facility policy stated that care plans are to be updated with the MDS/care conference schedule and as needed so they remain an accurate reflection of the resident and care needs. Review of the sampled records showed that Resident #5 was receiving spironolactone for chronic combined systolic and diastolic heart failure, and a quarterly MDS identified diuretics as a high-risk medication, but the care plan did not include a problem, goal, or interventions related to diuretic use. Resident #11 had a suprapubic catheter, but the care plan incorrectly referred to an indwelling urethral catheter and did not accurately reflect the resident’s current catheter status. Resident #27’s care plan described the resident as smoking regularly and included multiple smoking-related interventions, but a smoking risk assessment identified the resident as not safe to smoke under any circumstances. Resident #38 had diagnoses including legal blindness and mild cognitive impairment, and an admission MDS identified severe problems with thinking and memory; however, the record lacked documentation of a reported incident in which the resident’s husband brought her to their apartment without alerting staff, and the care plan did not address the possible elopement incident or the wanderguard that was placed in response. Resident #58’s care plan stated that the resident used bilateral amplifiers and kept them at bedside when not in use, but a nurse stated the amplifiers were kept in the top drawer of the nightstand and were no longer utilized per the family’s request, and the care plan was not revised to reflect that change.
MDS Coding Errors for Active Dx and Ileostomy
Penalty
Summary
The facility failed to ensure accurate coding of the MDS for 2 of 34 sampled residents. For Resident #6, a quarterly MDS coded post-traumatic stress disorder (PTSD) as an active diagnosis, but the resident stated he had never been diagnosed with PTSD. The medical record did not contain documentation of a PTSD diagnosis, behaviors, medical treatments, or nursing monitoring related to PTSD, and an administrative staff member confirmed the MDS was coded incorrectly. For Resident #64, the resident confirmed the presence of an ileostomy during interview, and the care plan stated the resident had an alteration in bowel status related to the ileostomy. However, an admission MDS failed to code the ileostomy in Section H for appliances. An administrative staff member stated it is an expectation that the MDS reflect a resident's current status.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance for two residents who required staff help with bowel and bladder needs. Facility policy stated that nursing assistants should assist with toileting needs per resident request and refer to the care plan for individualized toileting needs. Resident #67 had a diagnosis of fecal urgency and a care plan directing staff to provide assist x2 with toileting, offer toileting upon arising, after meals, before bed, and as requested. During interviews, the resident stated that at night staff did not respond when he turned on the light or call light, that he had wet his pants and had soiled himself because help did not come, and that a CNA told him he would have to wait when he said he needed to urinate. A CNA stated the resident had reported this issue several times and that it had been reported to the nurse. Resident #67's toileting record from February 15, 2026 through March 10, 2026 showed 72 occasions when staff failed to assist with toileting as care planned, with gaps of approximately 5 to 16 hours between assistance. Resident #4 stated that it sometimes took a long time for staff to help with toileting, if they came at all, and a strong bowel movement odor was noted in the room. Resident #4's care plan directed staff to offer toileting in the morning, after every meal, at bedtime, and as requested, but the toileting record from February 15, 2026 through March 10, 2026 showed 94 occasions when staff failed to assist per the care plan, with gaps of approximately 4 to 24 hours between assistance.
Medication Bottle Lacked Resident Label and Administration Instructions
Penalty
Summary
Medication labeling was not maintained in accordance with accepted professional principles for one sampled resident observed receiving eye drops. During observation on 03/11/26 at 1:03 p.m., a medication assistant prepared medications for Resident #46 by removing a bottle of lubricating eye drops from the medication cart drawer and administering it to the resident. The bottle identified a room number but did not have a label with the resident's name or instructions for administration. The report cites professional reference material describing the three checks for safe medication administration, including comparing the medication label against the MAR. During interview on 03/12/26 at 2:55 p.m., an administrative nurse confirmed that all medications should have labels.
Kitchen Sanitation and Freezer Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen areas. During observation of the kitchen, surveyors noted an accumulation of grease and grime on the ventilation system above the grill, as well as an accumulation of ice and condensation on the ceiling above and beside the fan of the walk-in freezer, with ice also present on boxes of food stored under the fan. Review of the facility policy stated that kitchen surfaces not in contact with food shall be cleaned enough to prevent the accumulation of grime. During interviews, two dietary supervisors stated that the vents above the grill and the walk-in freezer ceiling were not on a regular cleaning schedule and were cleaned as needed.
Infection Control and Hand Hygiene Failures During EBP Care
Penalty
Summary
Failure to follow infection control and prevention standards occurred for 2 residents who had enhanced barrier precautions (EBP) in place due to indwelling medical devices. Resident #64’s record showed EBP related to an ileostomy and indwelling catheter. During observation, a nurse entered the room after hand hygiene and donning gown and gloves, removed two buttock dressings, discarded them, cleansed the areas, removed soiled gloves, and then applied clean gloves without performing hand hygiene. The nurse retrieved a pen from a uniform pocket to date the new dressings, applied the dressings and barrier cream, removed gloves again, and again applied new gloves without hand hygiene before continuing care. Resident #86’s record showed a physician’s order and care plan for EBP due to an indwelling catheter. During observation, a CNA entered the room, performed hand hygiene, and applied gloves and a gown. The CNA drained urine from the catheter bag into a clear plastic container and then, while wearing the same gloves, transported the resident from the bathroom to the bedroom via wheelchair. The CNA did not remove the soiled gloves or perform hand hygiene before transporting the resident out of the bathroom. Facility policy reviewed during survey stated that residents with indwelling medical devices require EBP and that hand hygiene is required before and after care, after removing gloves, and after handling catheters or urine.
Failure to Ensure Food Service Staff Wore Required Beard Restraints
Penalty
Summary
The facility failed to ensure that food was prepared in accordance with professional standards for food service sanitation in the kitchen. Observations during multiple kitchen tours and tray line revealed that two male cooks were preparing food without wearing beard restraints, as required by both facility policy and the 2022 FDA Food Code. The facility's policy specifies that hairnets, caps, and beard restraints must be worn to prevent hair from contacting exposed food, clean equipment, utensils, and linens. During an interview, an administrative staff member confirmed that newly hired staff are instructed to keep facial hair trimmed, but there was no mention of enforcement regarding the use of beard restraints.
Inaccurate MDS Coding for High-Risk Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident, a physician's order for cefpodoxime, an antibiotic, was present, but the antibiotic was not coded on the resident's quarterly MDS. For another resident, a physician's order for escitalopram oxalate, an antidepressant, was documented, but the antidepressant was not coded on the quarterly MDS. In both cases, administrative staff confirmed that the medications should have been coded on the respective MDS assessments. Additionally, a third resident had a physician's order for aspirin, an antiplatelet medication, but no anticoagulant was ordered. However, facility staff coded both antiplatelet and anticoagulant medications on the resident's quarterly MDS. This incorrect coding was also confirmed by administrative staff during the survey. These inaccuracies in MDS coding resulted in the residents' assessments not accurately reflecting their current medication regimens.
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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) |
|---|---|---|---|---|
| Smp Health - St Catherine South | 1.9 mi | ★★★★★ | 0 | 0 |
| The Meadows On University | 2.4 mi | ★★★★★ | 2 | 0 |
| Eventide Lutheran Home | 2.9 mi | ★★★★★ | 1 | 0 |
| Bethany On University | 3.3 mi | ★★★★★ | 3 | 0 |
| Eventide Fargo | 3.8 mi | ★★★★★ | 4 | 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.