Eventide Fargo

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 22 sampled residents (Resident #7 and #8). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include:SECTION J: HEATLH CONDITIONSThe Long-Term Care Facility RAI User's Manual, revised October 2024, pages J 27-28, stated, . J1400 Prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.SECTION M: SKIN CONDITIONSThe Long-Term Care Facility RAI User's Manual, revised October 2024, page M 23-24, stated, . M0300F1: Enter the number of pressure ulcers that are unstageable related to slough [non-viable tissue] and/or eschar [dead or devitalized tissue].Review of Resident #7's medical record occurred on all days of survey and identified a terminal illness, hospice services beginning

on 05/22/25, and unstageable wounds to the right heel and great toe. A Wound Care Flow Sheet, dated 07/23/25, stated, Right heel - 3 [centimeters (cm)] x 2.7 [cm] x 0 [cm] unstageable, and R. [right] great toe is 0.6 [cm] x 0.6 [cm] x 0 [cm], unstageable. Eschar [thick, dry, crusty layer of dead tissue that forms over a wound]. The quarterly MDS, dated [DATE REDACTED], failed to identify a prognosis of life expectancy less than 6 months and the presence of an unstageable pressure ulcer.During an interview on 09/17/25 at 10:44 a.m.,

an MDS nurse (#4) agreed staff failed to code life expectancy of less than six months and an unstageable pressure ulcer.SECTION N: MEDICATIONSThe Long-Term Care Facility RAI User's Manual, revised October 2024, page N-4, stated, . N0415: High-Risk Drug Classes . Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days . C. Antidepressant .Review of Resident #8's medical record occurred on all days of survey. A physician's order, dated 07/31/25, stated, Venlafaxine [antidepressant medication] . one time a day for depression/anxiety. The significant change MDS, dated [DATE REDACTED], failed to identify the resident received an antidepressant.During an

interview on 09/17/25 at 4:06 p.m., an MDS nurse (#4) stated, I must have just missed it [coding venlafaxine].

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eventide Fargo

3225 51st St S Fargo, ND 58104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

This REQUIREMENT is NOT MET as evidenced by: Based on record review, policy and procedure review, professional reference review, and staff interview, the facility failed to provide the care and services for 1 of 1 sampled resident (Resident #5) on hemodialysis with a Permacath (a type of vascular access for dialysis). Failure to assess the hemodialysis vascular access site may result in complications and adverse effects, such as clotting and possible loss of the access site.

Residents Affected - Few

Findings include:

Review of the facility policy titled “Hemodialysis Access Sites” occurred on 09/18/25. This policy, revised April 2022, stated, “. The facility is responsible to . Provide ongoing monitoring and care of the resident's vascular access . Central Venous Access . Assess site BID [two times per day].

Observe for redness, warmth, drainage. Report problems immediately to physician/practitioner/dialysis center .

Review of the Core Curriculum for the Dialysis Technician - A Compressive Review of Dialysis, Fifth Edition, page 121 and 127 stated, . Vascular access makes chronic hemodialysis (HD) possible . An access is an HD patient's lifeline. Each access must be cared for as if it is the last one a patient can have. access failure means loss of the HD life-line. The access must be repaired or replaced - if the patient has a site left.

Access problems can cause hospital stays, surgery illness, limb loss, and death.

Review of Resident #5's medical record occurred on all days of survey and included a diagnosis of End Stage Renal Disease (ESRD). The current care plan stated, . Monitor CMS [circulation, motion, sensation] of extremity with access site per facility policy. Update provider/dialysis center if concerns are noted .

Resident receives dialysis (M/W/F) [Monday/Wednesday/Friday] .

Review of Resident #5's nurses' notes identified the following: *06/23/25 at 3:29 p.m., . No longer using fistula [a surgical connection between an artery and a vein to make it possible for hemodialysis]. Utilizing port to R [right] upper chest. Dressing in place. No obvious bruising, bleeding, redness, or drainage. *07/28/25 at 12:55 p.m., . returned from Dialysis early. Per report from [Resident #5], she has a clot to her dialysis cath and will need to have it replaced.*08/20/25 at 6:44 p.m., . Resident had dialysis today, her Perma Cath. blew during dialysis. *08/21/25 at 9:31 p.m., . Perma cath replacement.

During an interview on 09/17/25 at 2:36 p.m., a nurse manager (#5) confirmed the medical record lacked documentation of assessment of Resident #5's vascular access site twice a day.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eventide Fargo

3225 51st St S Fargo, ND 58104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, record review, review of facility policy, review of facility pharmacy guidelines, and staff interview, the facility failed to ensure accurate labeling of medications for 2 supplemental residents (Resident #22 and #55) observed during medication administration. Failure to obtain new medication labels from the pharmacy for oral medications and insulin or affix a label noting change in the directions, may result in residents receiving an incorrect dose of medications.Findings include:Review of the facility policy titled Medications: Administration and Storage occurred on 9/18/25. This policy revised March 2025, stated, . Medications will be administered according to the following directives . to provide safe and effective drug therapy for the residents . Medications will be labeled according to accepted pharmacy standards . Multi dose vials must be labeled when opened .Review of the facility's contracted pharmacy guidelines regarding label changes for existing medication orders occurred on 9/18/25. This guideline states, . To meet all federal and state labeling requirements . upon receiving a medication direction change [the facility], will place a 'refer to MAR' sticker on the existing medication and follow the MAR [medication administration record] directions when administering the medication to the resident. Pharmacy will supply a new and correct label .-Observation on 9/17/25 at 8:12 a.m. showed a nurse (#10) removed a medication container from the medication cart for Resident #22. The container label identified Norvasc 5mg [milligram], [heart medication] take 2 tablets daily . Review of Resident #22's current physician orders and MAR identified a dosage change on 06/11/25 from 2 tablets a day to 1 tablet a day. The container lacked a refer to MAR sticker. The nurse (#10) confirmed the label affixed to the container as incorrect, and staff failed to order a new label. -Observation on 9/17/25 at 4:38 p.m. showed a nurse (#11) removed a Novolog insulin pen from the medication cart for Resident #55. The insulin pen label included the resident's name and directions for administration which stated, Give Novolog flex pen 10 units SQ [subcutaneous] TID [three times a day]

before meals. Review of Resident #55's physician orders and MAR stated, Give Novolog, 8 units SQ TID

before meals. The insulin pen lacked a refer to MAR sticker over the label. The nurse (#11) confirmed the label affixed to the insulin pen as incorrect and staff failed to order a new label. During an interview on 9/17/25 at 4:10 p.m., an administrative nurse (#1) confirmed she expected staff to follow facility policy and ensure medications have a refer to MAR sticker or a correct dose label on them.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Eventide Fargo

3225 51st St S Fargo, ND 58104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During an interview on 09/16/25 at 3:00 p.m., an administrative nurse (#5) stated she expected staff to ensure all cushions have covers and are clean. - Review of Resident #17's medical record occurred on all days of survey. The current care plan stated, . has a . catheter in place . A progress note, dated 10/09/24 at 5:07 p.m., stated, . Family voiced concerns of catheter bag often leaking.

Observation on 09/16/25 at 7:54 a.m. showed an EBP sign outside of Resident #17's door. A CNA (#2) applied a gown and gloves and entered the resident's room. Resident #17 rested in bed with the catheter drainage bag hung on the side of bed and a dark, dried substance on the floor under the catheter bag. The CNA (#2) emptied the catheter bag into a container and a small amount of urine spilled on the floor. The CNA (#2) emptied the container into the toilet. The CNA removed the soiled gloves, performed hand hygiene, applied new gloves and transferred Resident #17 from bed to the toilet with the sit to stand lift. The CNA removed the resident's soiled brief, removed the soiled gloves, and without performing hand hygiene, removed the sit to stand lift and sling. The CNA (#2) then performed hand hygiene, applied new gloves, and performed morning cares. The CNA removed the soiled gloves, and without performing hand hygiene, brought the sit to stand lift back to the bathroom, applied new gloves, stood the resident up, performed perineal care, removed the soiled gloves. Without performing hand hygiene and applying new gloves, adjusted the resident's pants, transferred the resident to the wheelchair, placed the catheter bag under the wheelchair, made the bed, gathered the linen and garbage, applied new gloves and sanitized the lift. The CNA (#2) then removed the gown and gloves, performed hand hygiene and exited the room.

The CNA (#2) failed to clean the spilled urine from the floor, and failed to perform hand hygiene after removing soiled gloves, before touching other surfaces, and before applying clean gloves. - Review of Resident #13's medical record occurred on all days of survey. The current care plan stated, . catheter in place .

Observation on 09/16/25 at 4:07 p.m. showed an EBP sign on the wall outside of Resident #13's door. A CNA (#12) applied a gown and gloves, entered the resident's room, emptied the catheter bag, removed her gloves, and without performing hand hygiene, applied a new pair of gloves to dress Resident #13.

The CNA (#12) failed to perform hand hygiene after removing gloves and before applying clean gloves.

During an interview on 09/17/25 at 2:50 p.m., an administrative nurse (#6) confirmed she expected staff to perform hand hygiene after removing gloves, before applying clean gloves, and to clean the floor after a urine spill.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet