Fargo Health Care Center

In the surveyor’s words

From the most serious findings on record at Fargo Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 10, 2022

  Based on observation , interview and record review the facility failed to visually monitor and check every two hours for a resident present in the facility who was at risk for elopement, failed to implement its missing residents and elopement policy regarding the use and response to electronic monitoring devices. This applies to 1 of 5 sampled residents (R1). As a result, on 2/25/2022 R1 a cognitive impaired resident eloped from the facility without the facility staff being aware the resident was missing. A local emergency medical service (EMS) found R1 in a snowbank which put the resident at risk for frostbite or hypothermia. This was identified as an immediate jeopardy situation which began on 02/25/2022 when R1 eloped from the facility. […]

• Actual harm, isolatedF600Mar 26, 2026

  Based 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.Findings include:Facility's Reported Final Incident Investigation Report (1/29/2026), showed in part that on 1/26/2026 approximately around 3:45 PM, verbal altercation occurred between R2 and R3 over a cigarette lighter when returning from independent pass and standing on the facility's smoking patio. […]

• Actual harm, isolatedF689Nov 23, 2025

  Based 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. Findings include: 1. R1's ([DATE]) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact. R1's ([DATE]) Standing Order documented, in part Resident may have independent pass privileges. […]

• Actual harm, isolatedF600Jan 9, 2025

  Based 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. Findings include: R2 is an [AGE] year old with diagnosis including but not limited to: unspecified dementia, unspecified severe protein-calorie malnutrition, age - related osteoporosis without chronic pathological fracture, chronic pain and cognitive communication deficit. R3 is a [AGE] year old with diagnosis including but not limited to: bipolar disorder, generalized anxiety disorder, major depressive disorder, type 2 diabetes mellitus, restlessness and agitation. […]

• Actual harm, isolatedF600Dec 19, 2024

  Based 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. Findings include: The facility's Preliminary Incident Investigation Report to the local state agency dated 11/22/24 completed by V1 (Administrator) shows a report of physical abuse with alleged individual V11 (CNA/Certified Nursing Assistant) and R3. The facility's Completed Incident Investigation Report to the local state agency dated 11/27/24 competed by V1 documents, in part On 11/24/24 (should be 11/22/24) at approximately 11:45 am, R3's CNA (V14) was making rounds. V14 stated, I (V14) saw bleeding on the left arm. […]