Inspection·January 9, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. R7 is a [AGE] year old with diagnosis including but not limited to: essential hypertension, chronic obstructive pulmonary disease with acute exacerbation, pain in left leg, major depressive disorder and anxiety disorder. R7 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. On 01/06/2025 at 10:15 AM, V1 (Administrator) said that R2 had been transferred out of the facility per family's wishes after R2 was hit by another resident. On 01/06/2025 at 12:39 PM, V2 (DON/Director of Nursing) said that R3 was no longer in the facility and that she was sent out for aggressive behavior and allegedly punching R2 in the nose. On 01/06/2025 at 3:12 PM, R7 (R2 and R3's former roommate) was observed lying in her bed. R7 was asked about the incident involving R2 and R3. On 01/06/2025 at 3:14 PM, R7 said, The night that R2 was hit, I was asleep, but I heard her (R2) yell out and when I woke up, R3 was wide awake and walking around the room. R3 would always yell at and intimidate R2. She (R3) once told R2 that she wished that she (R2) would die. R2 would cry out a lot and the nurse would come in and check on R2 then leave. R3 was abusive to everyone and the staff knew it. She (R3) would cuss at staff and was always angry and demanding. At night, R2 would talk a lot and that would set R3 off. R3 would become very upset with R2. I didn't say anything because I was afraid of R3 retaliating against me. One night, I opened my eyes and R3 was standing near my bed. R3 was very unpredictable and always targeted R2. On 01/06/2025 at 1:10 PM, V8 (CNA/Certified Nurse Assistant) said, I saw R2 at around 7:30 AM (continued on next page) 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 Page 1 of 2 Event ID: 146169 Printed: 05/15/2026 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 146169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fargo Health Care Center 1512 West Fargo Chicago, IL 60626 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)