Health inspection·August 29, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of records the facility failed to provide admission contract/agreement packets in a timely manner to 5 out of 5 residents (R1, R6, R7, R8 and R9). Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1 medical diagnosis includes hypertension, major depression (single episode), bipolar disorder, anxiety disorder. Per MDS assessment of R1 dated 06/20/2025, R1 has a BIMS (Brief Interview of Mental Status) score of 15 or cognition is intact. On 08/26/2025 at 10:12 AM, R1 stated that facility let him sign a contract for services recently. R1 presented a Resident admission Packet. R1 stated that it is a contract for services and terms and condition for resident to be in the facility. R1 stated that he dislikes the contract because there are blank areas and missing pages. R1 stated that facility did not give him enough time to review the contract. R1 stated that V1 (Administrator) called him to a meeting. In that meeting, V1 told him that he told other residents not to sign the contract which was not true. V1 stated that he was upset because the contract may change his living arrangement. R1 said, I have been living for two (2) and a half year and I don't want to change what I can and cannot do because of the contract. On 08/26/2025 at 12:36 PM, V6 (MDS Coordinator/Licensed Practical Nurse) stated that the only time she encountered R1 about admission contract was when there was a meeting on the conference room. R1 came in saying don't force me to sign. V1 (Administrator) told R1 to talk in her office. On 08/26/2025 at 01:01 PM V3 (Director of Social Services/PRSD) stated that admission contract includes policies and regulation, resident rights, position and payment. Facility is three (3) years behind in providing resident admission contracts to residents already in the facility. For that reason, facility hired a consultant (V5). V3 stated that admission contract packet needs to be provided during admission. V3 stated that admission contract is important because it provides information about living in a nursing home. V3 stated that R1 was provided admission contract about a month ago. Per R1's record (face sheet), R1 has been a resident in the facility since 01/10/2023. On 08/26/2025 at 01:29 PM, V1 (Administrator) stated that every resident coming in the facility needs admission contract. V1 stated that about seven (7) months ago when she did an audit there are residents that was not offered an admission contract. V1 stated that V5 (Social Service Consultant/Outside Vendor) was hired to address this issue by offering admission contracts to residents. V1 stated that admission contracts need to be given to residents upon admission. V1 stated that R1 did not sign the admission contract. V1 provided list of five (5) residents that does not have admission contracts based on facility's audit. Five (5) residents are as follows: R1 first admission date 01/10/2023, R6 first admission date 10/05/2023, R7 first admission date 02/11/2025, R8 first admission date 10/03/2023 and R9 first admission date 06/03/2024. Majority of residents (R1, R6, R8 and R9) were without admission contracts for more than a year after admitted in the facility. Facility was requested to provide policy and procedure to address concerns related to residents not provided Resident Admissions Packet / Contract during or (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 08/29/2025 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)