Eventide Fargo: Assessment Accuracy Failures - ND
The medication error at Eventide Fargo represented a pattern federal inspectors documented during their September visit. Nurses administered medications using incorrect dosage labels while ignoring facility policy designed to prevent exactly these mistakes.
Resident 22's Norvasc container still displayed instructions to "take 2 tablets daily" even though the resident's doctor had reduced the dosage to one tablet daily three months earlier, in June. The heart medication container lacked any sticker directing staff to check current orders.
Nurse 10 confirmed to inspectors that the label was wrong and acknowledged staff had failed to order a corrected label from the pharmacy.
The same day, inspectors observed another medication error during the evening shift. Nurse 11 retrieved an insulin pen for Resident 55 that instructed "Give Novolog flex pen 10 units" three times daily before meals. The resident's actual prescription called for 8 units three times daily.
Again, no "refer to MAR" sticker covered the incorrect label. The insulin pen had been dispensed with wrong dosage instructions, and staff never requested a corrected label.
Nurse 11 admitted the insulin pen label was incorrect and that staff had not obtained a new label.
The facility's own policy, revised in March, explicitly requires medications to be "labeled according to accepted pharmacy standards." The contracted pharmacy's guidelines state that when medication directions change, staff must "place a 'refer to MAR' sticker on the existing medication and follow the MAR directions when administering the medication to the resident."
The pharmacy promises to "supply a new and correct label" when notified of changes.
Administrative Nurse 1 confirmed during interviews that she expected staff to follow facility policy and ensure medications carried either correct dosage labels or "refer to MAR" stickers.
Neither medication container met these requirements.
The violations occurred despite the facility's stated commitment to "provide safe and effective drug therapy for the residents." The policy acknowledges that proper labeling follows "accepted pharmacy standards" and requires multi-dose vials to be labeled when opened.
Federal regulations require nursing homes to ensure all drugs are "labeled in accordance with currently accepted professional principles." Medications must be stored in locked compartments with controlled drugs kept separately.
The inspection report notes that failure to obtain new medication labels or affix stickers noting dosage changes "may result in residents receiving an incorrect dose of medications."
For Resident 22, following the outdated Norvasc label would have meant receiving double the prescribed heart medication dose. The resident had been on the reduced dosage for more than three months when inspectors observed the labeling violation.
Resident 55 faced potential insulin overdose from the mislabeled pen. Insulin dosing errors can cause dangerous blood sugar fluctuations in diabetic residents.
Both residents were among those identified as "supplemental residents" during the medication administration observation. The inspection classified the violations as causing "minimal harm or potential for actual harm" affecting "few" residents.
The facility's medication cart system relies on nurses checking both container labels and medication administration records before dispensing drugs. When labels contradict current orders, facility policy requires either updated labels from the pharmacy or temporary stickers directing staff to current dosing instructions.
Neither safeguard protected the two residents inspectors observed.
The September inspection was conducted in response to complaints about the facility. Eventide Fargo operates at 3225 51st Street South in Fargo, serving residents who depend on accurate medication administration for conditions including heart disease and diabetes.
The administrative nurse's acknowledgment that staff should follow labeling policies suggests awareness of proper procedures. The observed violations indicate a gap between policy requirements and actual nursing practice during medication administration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eventide Fargo from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
EVENTIDE FARGO in FARGO, ND was cited for violations during a health inspection on September 18, 2025.
The medication error at Eventide Fargo represented a pattern federal inspectors documented during their September visit.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.