Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sheyenne Crossings Care Center/tcu during CMS and state inspections, most recent first.
The facility failed to ensure the secure storage of medications and controlled substances in the TCU. A medication aide did not store narcotic medication cards in a locked box within the medication cart, and the medication storage room and narcotic cupboard doors were found unlocked and ajar. An administrative nurse confirmed the expectation for these to be locked, and the facility lacked a policy on medication storage.
The facility failed to follow infection control standards, including Enhanced Barrier Precautions (EBP) and hand hygiene, for several residents. Staff did not wear required PPE during resident transfers and neglected to disinfect equipment or perform hand hygiene between glove changes. These deficiencies were observed during care activities, such as transferring residents and performing dressing changes, and were confirmed by an administrative nurse.
The facility failed to accurately document the code status for three residents, leading to discrepancies between the Uniform Code Level Directives and other medical records. One resident's care plan indicated a higher level of intervention than desired, while another resident's records lacked any code status identification. A third resident's records inaccurately reflected a higher intervention level, despite confirmation of a lower level by the resident and significant other.
A facility failed to accurately code a resident's MDS, omitting a nasal fracture in section I4000 and incorrectly coding fall history in section J1800. Despite documentation of a fall and nasal fracture, the MDS did not reflect these events, and a nurse confirmed the miscoding during an interview.
A facility failed to use a gait belt during a resident's transfer, despite the resident's history of falls and cognitive issues. The facility's policy requires gait belts for all assisted transfers, but a CNA assisted the resident from bed to wheelchair and then to the toilet without one. An administrative nurse confirmed the expectation to use gait belts, highlighting a lapse in following the care plan and facility policy.
Failure to Secure Medications and Controlled Substances
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications and controlled substances in the Transitional Care Unit (TCU). During an observation, a medication aide was found not storing narcotic medication cards in a locked box within the medication cart, although the cart itself was locked when unattended. Additionally, the TCU medication storage room door and the narcotic storage cupboard door were found unlocked and ajar, with non-nursing personnel present. A staff nurse was unaware of the reason for the unlocked doors. An administrative nurse confirmed that the expectation was for staff to lock the medication storage room door and narcotic cupboard doors, and to store narcotics in the lock box in the medication cart. The facility also failed to provide a policy on the storage of medications and controlled substances.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for several residents, as observed during the survey. Specifically, staff did not follow Enhanced Barrier Precautions (EBP) for residents requiring such measures. For instance, a certified nurse aide (CNA) transferred a resident with an indwelling catheter without donning gloves and a gown, despite the care plan indicating the need for EBP. Similarly, another CNA and a nurse entered a resident's room and performed a transfer using a mechanical lift without wearing the required personal protective equipment (PPE). Additionally, a CNA assisting a resident with ulcers to the feet failed to perform hand hygiene before exiting the room after assisting with a transfer. The report also highlights multiple instances where staff did not perform hand hygiene between glove changes or disinfect equipment after use. For example, CNAs failed to disinfect a full body mechanical lift after transferring residents and did not perform hand hygiene upon entering or exiting rooms. In one case, a licensed nurse did not clean a bedside table with a germicidal wipe before placing dressing supplies on it. These lapses in infection control practices were confirmed by an administrative nurse, who stated that staff are expected to complete hand hygiene during resident care and sanitize equipment after each use.
Inaccurate Code Status Documentation for Residents
Penalty
Summary
The facility failed to ensure that all forms of communication related to code level status accurately reflected the residents' wishes for three residents. For Resident #14, the Uniform Code Level Directives indicated a Code Level 2, which means no intervention in the event of a cardiac or respiratory arrest. However, the care plan inaccurately identified a Code Level 1, which involves using all available reasonable technology in such events. An administrative staff member confirmed the discrepancy in the care plan. For Resident #30, the Uniform Code Level Directives indicated a Code Level 2, but the face sheet, physician order summary, and EMAR did not identify any code status, while the care plan inaccurately identified a Code Level 1. An administrative nurse confirmed the failure to identify the current code status in the resident's records. Similarly, for Resident #48, the Uniform Code Level Directives indicated a Code Level 2, but the face sheet, physician order summary, EMAR, and care plan all inaccurately indicated a Code Level 1. The resident and her significant other verified that Code Level 2 was accurate.
Inaccurate MDS Coding for Resident's Nasal Fracture and Fall History
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for a resident, which affected the reflection of the resident's current status and needs. Specifically, the facility did not code the resident's nasal fracture in the MDS section I4000, despite documentation in the medical record indicating a fall and subsequent nasal fracture. This oversight was confirmed during an interview with a nurse, who acknowledged the failure to code the nasal fracture on the significant change MDS. Additionally, the facility incorrectly coded the resident's fall history in the MDS section J1800. The medical record did not support the coding of a fall occurring after the prior assessment date, yet the significant change MDS indicated a fall had occurred. This discrepancy was also confirmed by a nurse during an interview, who admitted the miscoding of the significant change MDS for falls.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices during a transfer for one of the two sampled residents. The deficiency was identified through observation, record review, facility policy review, and staff interviews. The facility's policy, revised in January 2024, mandates the use of a gait belt for all assisted transfers and ambulation. However, during an observation on May 2, 2024, a certified nurse aide assisted a resident with a history of falling and cognitive function issues from the bed to a wheelchair and then to the toilet without using a gait belt. The resident's care plan required assistance with ambulation, transfers, and toileting using a front-wheeled walker. An administrative nurse confirmed that staff were expected to use a gait belt during all assisted transfers, indicating a failure to adhere to the facility's policy and care plan requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Fargo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eventide Fargo | 1.5 mi | — | 4 | 0 |
| Smp Health - St Catherine South | 4.8 mi | — | 0 | 0 |
| The Meadows On University | 4.8 mi | — | 2 | 0 |
| Bethany On University | 4.9 mi | — | 3 | 0 |
| Fargo Elim Health Care Center | 5.2 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.