Cycle 1
Health 2024-12-18 · Fire 2024-12-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
West Fargo, ND
Sheyenne Crossings Care Center/Tcu
4-star overall rating with 4-star inspections with 4 recent health deficiencies
125 13th Avenue West, West Fargo, ND
(701) 478-6100
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-03-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.29
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.22
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,458
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9973
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.65
Baseline 22.26% · Performance 20.61% · Measure score 2.65 · Achievement 1.78 · Improvement 2.65
Healthcare-associated infections
3.91
Baseline 8.56% · Performance 6.99% · Measure score 3.91 · Achievement 2.84 · Improvement 3.91
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.70
Baseline 4.81 hours · Performance 4.98 hours · Measure score 6.70 · Achievement 6.70 · Improvement 1.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.98% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 5.71% · Lower 95% interval 5.86% |
| Discharge to community | 39.25% |
50.57%
11.3 pts worse
|
Worse than the National Rate · Eligible stays 141 · Observed rate 36.17% · Lower 95% interval 30.75% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 129 · Denominator 129 |
| Falls with major injury | 1.55% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 129 |
| Discharge self-care score | 38.68% |
53.69%
15 pts worse
|
Numerator 41 · Denominator 106 |
| Discharge mobility score | 49.06% |
50.94%
1.9 pts worse
|
Numerator 52 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 3.88% |
2.29%
1.6 pts worse
|
Numerator 5 · Denominator 129 · Adjusted rate 3.28% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 5% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 14.38% |
8.2%
6.2 pts better
|
Numerator 22 · Denominator 153 |
| Staff flu vaccination coverage | 96.41% |
42%
54.4 pts better
|
Numerator 188 · Denominator 195 |
| Discharge function score | 47.17% |
56.45%
9.3 pts worse
|
Numerator 50 · Denominator 106 |
| Transfer of health information to provider | 95.56% |
95.95%
0.4 pts worse
|
Numerator 43 · Denominator 45 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 22 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.4
0.5 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.9
1.3 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
98.3%
3.2 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 80.8% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.8%
1.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
5.1%
2.2 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.8% · Q3 4.0% · Q4 3.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.4%
4.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
5.5%
1.9 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.5% · Q3 6.8% · Q4 11.4% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
17.4%
1.8 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 16.0% · Q3 15.6% · Q4 14.6% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
23.4%
10.1 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 17.9% · Q3 12.8% · Q4 10.5% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.2% |
19.0%
6.2 pts worse
|
16.3%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 29.0% · Q3 15.9% · Q4 25.1% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
20.1%
7 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 21.3% · Q3 6.8% · Q4 6.8% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
3.1%
0.1 pts better
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 4.0% · Q4 4.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
25.2%
1.6 pts better
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 26.3% · Q3 30.7% · Q4 27.3% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.3%
1.1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 10.3% · Q3 10.0% · Q4 3.5% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
93.6%
5.1 pts worse
|
81.7%
6.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 91.4% · Q3 95.5% · Q4 77.6% · 4Q avg 88.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
10.7%
0.9 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 8.6% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
88.3%
5 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
20.5%
4.4 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 23.5% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-20 · Fire 2022-10-20
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-13
E · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-12-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-05-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-24
E · Potential for more than minimal harm
2023-11-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-20
E · Potential for more than minimal harm
2022-10-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-10-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-10-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-10-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-22
Penalties and ownership
What sits behind the stars
Ownership
Blue Stone Therapy Inc
Operational/Managerial Control · Organization
Bock, Jodee
Corporate Director · Individual
Brandt, Terry
Corporate Director · Individual
Brasel, Melissa
Operational/Managerial Control · Individual
Bye, Robert
Corporate Officer · Individual
Dahl-Wagner, Maegan
Operational/Managerial Control · Individual
Eventide
5% Or Greater Direct Ownership Interest · Organization
Fischbach, Tyler
Corporate Director · Individual
Gulbranson, Patrick
Corporate Director · Individual
Halvorson, Joseph
Corporate Director · Individual
Heppner, Alexandra
Operational/Managerial Control · Individual
Hvidston, Luke
Corporate Director · Individual
Hvidston, Luke
Corporate Officer · Individual
Johnson, Vikki
Corporate Director · Individual
Johnson, Vikki
Corporate Officer · Individual
Johnsrud, Jackson
Operational/Managerial Control · Individual
Larson-Casselton, Cindy
Corporate Director · Individual
Lee, Judith
Corporate Director · Individual
Lunak, Brandon
Corporate Director · Individual
Ohe, Darin
Operational/Managerial Control · Individual
Rahman, Cassidy
Operational/Managerial Control · Individual
Riewer, Jon
Corporate Officer · Individual
Sand, Michael
Operational/Managerial Control · Individual
Schafer, Eric
Corporate Director · Individual
Seljevold, Peter
Corporate Director · Individual
Swenson, Karla
Corporate Director · Individual
Whitmore, Ashton
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Eventide Fargo
Fargo, ND
3-star overall rating with 3-star inspections with $9,030 in total fines with 5 recent health deficiencies
#2
Smp Health - St Catherine South
Fargo, ND
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
The Meadows On University
Fargo, ND
2-star overall rating with 2-star inspections with $41,041 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out