Eventide Fargo: Dialysis Care Safety Failures - ND
The facility failed to ensure accurate medication labeling for at least two residents, creating potential for dangerous overdoses or underdoses of critical medications including heart drugs and insulin.
On September 17 at 8:12 a.m., inspectors observed nurse #10 remove a Norvasc container from the medication cart for Resident #22. The heart medication label instructed "take 2 tablets daily," but the resident's current physician orders called for just 1 tablet daily — a dosage change made three months earlier on June 11.
The container lacked the required "refer to MAR" sticker that would alert staff to follow the medication administration record instead of the outdated label. Nurse #10 confirmed the label was incorrect and that staff had failed to order a new label from the pharmacy.
That same afternoon at 4:38 p.m., inspectors witnessed a similar violation with insulin administration. Nurse #11 retrieved a Novolog insulin pen for Resident #55 that was labeled for 10 units three times daily before meals. The resident's actual physician orders specified 8 units three times daily — a 25 percent difference in dosage.
Again, the insulin pen lacked the mandatory "refer to MAR" sticker. Nurse #11 acknowledged the label showed an incorrect dosage and that staff had not obtained proper labeling.
The facility's own policy, revised in March 2025, requires medications to be "labeled according to accepted pharmacy standards." The contracted pharmacy guidelines specifically state that upon receiving a medication direction change, facilities must place a "refer to MAR" sticker on existing medication and follow the medication administration record directions.
Administrative nurse #1 confirmed during a September 17 interview that staff were expected to follow facility policy and ensure medications have either a "refer to MAR" sticker or correct dose labels.
The violations occurred despite clear protocols designed to prevent medication errors. The facility's pharmacy guidelines require new and correct labels to be supplied when dosages change, or temporary stickers to redirect staff to current orders.
Federal regulations mandate that all drugs and biologicals be labeled according to currently accepted professional principles to ensure safe medication administration. The labeling failures at Eventide Fargo created conditions where residents could receive incorrect medication doses.
For Resident #22, the mislabeled heart medication could have resulted in receiving double the prescribed Norvasc dosage. The blood pressure medication, when taken in excess, can cause dangerous drops in blood pressure, dizziness, and falls.
Resident #55 faced potential complications from insulin misdosing. The 2-unit difference between the label and actual orders represents a significant variance that could lead to blood sugar spikes or dangerous hypoglycemic episodes requiring emergency intervention.
The inspection findings revealed systemic failures in medication management protocols. Multiple staff members encountered incorrect labels but failed to follow established procedures for obtaining proper labeling or applying temporary correction stickers.
Neither nurse observed during the violations had taken steps to correct the labeling problems, despite facility policy requiring accurate medication labels and pharmacy guidelines providing specific procedures for handling dosage changes.
The medication errors occurred months after the facility revised its medication administration policy in March 2025, indicating recent policy updates had not translated into consistent staff compliance with labeling requirements.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting few residents. However, medication labeling errors can escalate quickly, particularly with drugs like insulin where precise dosing is critical for resident safety.
The September 18 inspection was conducted in response to complaints about facility operations, suggesting ongoing concerns about care quality at the 3225 51st Street South facility.
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.
On September 17 at 8:12 a.m., inspectors observed nurse #10 remove a Norvasc container from the medication cart for Resident #22.
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.