Inspection·November 23, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few and for the facility to know if anything was missing. Secondly, to check if they have sharp objects on them, including scissors, so they would not be able to use to harm themselves and others. On [DATE] at 11:12am, V16 stated it was around 2am-3am when she (R1) pulled the call light. She (V16) went inside, and her hands were covered in blanket all the way to her shoulder covered. She (R1) said she was not feeling good and wanted to go to the hospital. V16 stated she opened the blanket to check her blood pressure that was when she saw the dried blood on her right hand. She asked what happened and she said she cut herself. She saw blood and put her on 1:1 supervision. She (V16) asked her (R1) what she used, and she said she used scissors. (V17-Security) got the scissors and put it in the office. She did not have the time to ask the resident where she got the scissors because 911 came. When she came back from the hospital, she got 2 stitches. V16 stated when a new resident is admitted , the staff would do inventory of the resident's belongings and enter it in the computer and check whatever she brought to know what she had. Anything that is dangerous to self and others, or anything that they are not supposed to have with them is removed. The purpose is to know what they brought. The resident was admitted to the facility because they have a problem, it is not expected for a resident to have scissors with them. Residents with history of depression should not have scissors with them. On [DATE] at 12:15pm, V17 (security) stated he got the scissors and put the scissors in a rubber glove. The scissors had blood on them and were sharp enough that if you would really try to cut yourself, you would. The incident should not happen. Staff should search belongings and see what they have, like scissors, knives, and stuff like that. On [DATE] at 4:07pm, V2 (Director of Nursing) stated the expectation is not to have any type of sharp objects that could potentially harm themselves, staff, and another resident. On [DATE] at 4:17 V2 stated the cut on her wrist was a serious injury because she (R1) received 2 stitches to treat the cut. On [DATE] at 5:24pm, V1 (Administrator) stated it was absolutely necessary for the resident's environment to be free of accident hazards to ensure residents were safe at all times. Residents should still be safe if they have mental issues. V1 stated it was not expected of residents to have access to any hazardous materials including guns, drugs, scissors, and needles. 2. On [DATE] at 3:33pm, R9 stated she has been at the facility since [DATE] and stated she had scissors from another facility and staff took the scissors from her a month ago and she did not know why staff took her scissors. R9 stated she used the scissors to cut her hair. R9 stated honestly, she did not remember if facility did an inventory of her belongings. On [DATE] at 4:24pm, V5 (Psychiatric Rehabilitation Services Coordinator/PRSD) stated (V4 - PRSD) instructed her to go with (V6-Activity Director) to search her (R9's) room because she has been hiding medications. They did a room search and saw a pair of scissors and a box full of medications. On [DATE] at 3:37pm, V6 (Activity Director) stated she (R9) showed her medications to her Primary and the Primary informed the nurse about it. Then (V4) told them (V5 and V6) to do a search in her room. V6 stated she found the scissors in a plastic bag, and she (R9) said she got it from her previous nursing home. V6 also stated she (R9) had a candle and a lot of medications in plastic box, more than 50 but less than 100 medications of different colors and different sizes. V6 stated she showed the medications to (V2), and she (V6) kept the scissors and candle in the Activity storage room. V6 stated she (R9) did not say where she got the medications. On [DATE] at 4:31pm, V19 (Licensed Practice Nurse/Restorative Nurse) stated he worked double shifts on [DATE]. During the morning shift, he gave her (R9) 2 capsules of Duloxetine 20mg (milligrams). Then on evening shift, (V20 -R9'S Primary Care Physician) came. He was passing medications, and he (V20) came to talk to him with the resident and ask what medications the two capsules in her (R9)'s hand were. He told him it was her psych meds, Duloxetine. He (V19) showed (V20) the medication dispensing card (BINGO card) of her (R9)'s Duloxetine and it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 2 of 4 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 11/23/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few the same medication when compared. V19 stated she did not want psych meds anymore and asked her why she just told him. V19 assumed she hid the medications under her tongue. V19 stated he checked her mouth, but he was not going to lie, he did not check under her tongue. V19 stated when giving medication, the expectation was to stay until the medications were swallowed. To check under the tongue to make sure she swallowed her medications. V19 stated Duloxetine was a psych med and it could lead to a behavior symptoms if not taken. V19 stated he did a random check of her room, not a thorough check and stated he should have done a thorough check of her room to ensure there are no other medications in her room because she could potentially overdose. V19 stated he was sure he informed (V2) the day the incident happened. On [DATE] at 3:52pm, V2 stated the incident happened on [DATE] and the search happened on [DATE] and found medications without labels. V2 stated the expectation was to do the room search immediately on [DATE] because she could be harmed as well as other residents in the room. V2 stated he (V19) did not tell her about the incident on [DATE]. On [DATE] at 4:05pm, V2 stated the nurse had to follow the rights of medication administration and to make sure the resident swallows the medication to ensure the resident was receiving the therapeutic benefits of the medication. If a resident had certain behaviors of holding on to the medications and took all of them at once, the resident could overdose and that was going to be a problem because the resident could die. On [DATE] at 4:07pm, V2 stated all information should have been shared with her sooner, not to put resident at harm, the expectation is not to have sharp objects that could potentially harm themselves, staff, and another resident. Initial inventory checks are done on the items a resident has on admission. There are house rules and the resident signs a contract agreeing to the rules. On [DATE] at 5:24pm, V1 (Administrator) stated it was absolutely necessary for the resident's environment to be free of accident hazards to ensure residents were safe at all times. Resident should still be safe if they have mental issues. V1 stated it was not expected of residents to have access to any hazardous materials including guns, drugs, scissors, and needles. R9's ([DATE]) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R9's mental status as cognitively intact. R9's ([DATE]) Standing Order documented, in part Resident May have independent pass privileges. R9's (10/2025) MAR (Medication Administration Record) documented, in part Cymbalta 20 mg capsule. Delayed release. Dispensed: duloxetine 20 mg capsule, delayed release. Give 2 capsules (40mg) by oral route once daily. Start date: [DATE]. Of note, last given on [DATE] by V19 (Licensed Practice Nurse/Restorative Aide). R9's ([DATE]) Progress Notes documented, in part Resident was given her duloxetine 20mg 2 caps QD (every day) in the morning, resident apparently hid the medication under her tongue, took the meds out of her mouth and kept it. During resident's PCP (Primary Care Physician) rounds later in the day, resident brought out the meds and showed it to him that she doesn't want to take the medication anymore. (PCP) then asked writer what she was talking about, writer took the pills from resident and explained to the Doctor that those are psych meds that were given to her in the morning. Writer then asked resident if she told any staff she does not want the meds anymore, she confirmed she is yet to inform any nurse about her decision. Furthermore, writer asked why she is refusing the medication, she said I don't want it anymore, I'm fine this was said in the presence of her PCP. Psych MD notified of resident's decision and gave a new order for medication to be discontinued. Order noted and carried out. Entered By: V19 (Licensed Practice Nurse/Restorative Nurse. R9's ([DATE]) care plan documented, in part The resident exhibits the symptom of resisting care which is related to: (x) Psychiatric illness, severe mental illness. (X) Hiding, hoarding medications and other non-allowed items at bedside or other places within the room. The ([DATE]) email correspondence with V1 (Administrator) and V2 (Director of Nursing) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 3 of 4 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 11/23/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented, in part No residents are allowed to have any hazardous items, for example scissors in their possession while in our facility. Such items could potentially cause harm if they are handled inappropriately or used without supervision. The (undated) House Rules and Behavior Expectation documented in part Residents of Fargo Health Care Center are expected to conduct themselves in accordance with the facility philosophy which promotes personal responsibility and dignified behavior. 3. All residents are asked to come to the nursing station for medications at the prescribed times, if physically able. Medications must be consumed in the nurses' presence while at the nursing station. 9. The following items are considered contraband and are not allowed in resident rooms: medication of any type, any sharp or dangerous object (knives, razors, needles, letter openers, box cutters, certain nail clippers, pins, tacks, etc.) cleaning agents, certain shaving cremes, weapons, and drug paraphernalia. 15. This nursing facility reserves the right to check/search all bags and personal belongings of all residents, staff, and visitors upon entering and exit from the building to prevent anyone from bringing in contraband or weapons. This is to ensure all our residents, staff and visitors are safe at all times. Resident rooms may also be checked/searched at the discretion of staff. Two staff members and resident must be present for this procedure. It is our desire to maintain a safe environment for all parties. The (undated) Routine Resident Checks, Safety Room Checks, and Outdoor Area (Patio) documented, in part Policy Statement. Routine resident checks shall be made to assure that the resident's safety and well-being are maintained. On occasion it may be required for facility staff to check a resident's room for contraband or other items not safe in this environment. Policy Interpretation and Implementation. 4. To provide safety to all residents, Resident Room, Dining Rooms, and outside areas will be checked for any concerns related to unsafe items (contraband such as Alcohol, Medications, drug paraphernalia, and/or items that may be used by resident or others to cause harm). Resident upon entering the facility from independent pass, the facility reserves the rights to check bags or resident coat/jacket and pockets. If resident is observed with unapproved items, appears to be under the influence, and/or has a history of safety concerns such as alcohol, illegal substances, etc., the facility will conduct search, with resident present to ensure the resident and other residents in the facility are safe and free from harm. 5. If facility staff identify and safety concerns related to the environment or items or substances that pose risks to residents' health and safety and are in plain view, they will be confiscated, and all concerns will be addressed to the Administrator immediately. The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must provide services to keep your physical and mental health at their highest practicable levels. Your facility must be safe. The (07/2024) Medication Administration Policy documented, in part Policy: All medications must be administered safely and effectively. Remain with resident until all medications have been fully swallowed. Event ID: Facility ID: 146169 If continuation sheet Page 4 of 4