Eventide Fargo: Infection Control Failures - ND
Federal inspectors found two cases of mislabeled medications at Eventide Fargo during a September complaint investigation. In both instances, nurses administered drugs with incorrect dosage information printed on the containers.
On September 17 at 8:12 a.m., inspectors watched nurse #10 remove a Norvasc container for Resident #22. The label read "take 2 tablets daily" for the heart medication. But the resident's physician had changed the order three months earlier to one tablet daily.
The container lacked the required "refer to MAR" sticker that pharmacy guidelines mandate when dosages change. The nurse confirmed the label was wrong and that staff had failed to order a new one.
Later that day at 4:38 p.m., nurse #11 retrieved a Novolog insulin pen for Resident #55. The pen's label directed "10 units subcutaneous three times a day before meals." The resident's actual order called for 8 units three times daily.
Again, no sticker indicated the label change. The nurse acknowledged the incorrect labeling and confirmed staff hadn't requested proper labels from the pharmacy.
Administrative nurse #1 told inspectors during a September 17 interview that she expected staff to follow facility policy requiring either correct dose labels or "refer to MAR" stickers on medications.
The facility's March 2025 medication policy states drugs "will be labeled according to accepted pharmacy standards" to "provide safe and effective drug therapy for residents." The policy specifically requires multi-dose vials to be labeled when opened.
Eventide Fargo's contracted pharmacy guidelines address label changes directly. When facilities receive medication direction changes, they must "place a 'refer to MAR' sticker on the existing medication and follow the MAR directions when administering." The pharmacy then supplies new, correct labels.
Neither medication container observed by inspectors followed these procedures.
The Norvasc case represented a particularly significant labeling error. Resident #22's dosage had been cut in half on June 11, but the original "2 tablets daily" instruction remained on the container for over three months. Without the required sticker system, nurses relied on memory or separate documentation to determine the correct dose.
For Resident #55, the insulin pen showed 10 units while orders specified 8 units. Insulin dosing requires precise administration, as incorrect amounts can cause dangerous blood sugar fluctuations in diabetic residents.
The inspection found the facility failed to ensure accurate medication labeling for residents, creating potential for dosing errors. Federal regulations require nursing homes to store and label drugs according to professional standards, with controlled substances in separately locked compartments.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, medication errors represent one of the most serious safety risks in nursing homes, where residents often take multiple prescriptions daily.
The facility's own policy acknowledges the importance of proper labeling for resident safety. Staff interviews confirmed awareness of requirements but showed systematic failure to implement the sticker system or request updated labels when dosages changed.
Both observed cases involved chronic medications that residents likely received daily. The heart medication error persisted for months, while the insulin labeling discrepancy continued without correction despite the pharmacy's established procedures for handling such changes.
Federal inspectors completed their review on September 18, documenting the medication labeling failures as part of a complaint investigation 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.
Federal inspectors found two cases of mislabeled medications at Eventide Fargo during a September complaint investigation.
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.