Sheyenne Crossings Care Center/Tcu

In the surveyor’s words

From the most serious findings on record at Sheyenne Crossings Care Center/Tcu, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 15, 2021

  Based on record review, review of the facility incident investigation, staff interview, and review of operator's manual, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 2 of 2 closed records (Resident #60 and #61) reviewed with Hoyer (full body mechanical lift) transfers. Failure to safely utilize a mechanical lift has the potential for injury for Resident #60 and resulted in a fall with serious injury for Resident #61, and placed all residents requiring this type of transfer at risk for accidents and/or injury. […]

• No harm, potential for more than minimal, patternF761Dec 18, 2024

  Based on observation and staff interview, the facility failed to ensure safe and secure storage of medications and controlled substances (narcotics) in 1 of 1 unit (Transitional Care Unit (TCU)) observed. Failure to secure medications and controlled substances may result in unauthorized access to medications. Findings include: The facility failed to provide a policy on storage of medications and controlled substances. - Observation on 12/18/24 at 1:37 p.m., of the TCU medication cart with a medication aide (MA) (#5) showed narcotic medication cards within the cart not stored in a locked box. The MA stated, When I walk away, I lock the cart and put the keys in my pocket. I do not lock these in a lock box [referencing narcotic cards]. […]

• No harm, potential for more than minimal, patternF880Dec 18, 2024

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 16 sampled residents (Resident #8, #9, #17, #32, and #36) and 2 supplemental residents (#7 and #46) observed during cares/dressing change. Failure to practice infection control standards related to hand hygiene, enhanced barrier precautions (EBP), during a dressing change, and disinfection of equipment has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene Policy occurred on 12/18/24. This policy, revised January 2024, stated, . Hand hygiene will be done a.) Before and After resident contact (before you leave the room) . […]

• No harm, potential for more than minimal, patternF812Nov 16, 2023

  Based on observation, review of the Food and Drug Administration (FDA) 2022 Food Code, and staff interview, the facility failed to store food under sanitary conditions in 1 of 1 kitchen. Failure to store food in a sanitary environment in the walk-in freezer has the potential to result in contamination of food and could result in a foodborne illness. Findings include: The 2022 Food Code, pages 81-82, stated, 3-305.11 Food Storage. FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; . 3-305.12 Food Storage, Prohibited Areas. FOOD may not be stored: . (G) Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed; . […]

• No harm, potential for more than minimal, patternF585Oct 20, 2022

  Based on observation, resident interviews, and review of resident council meeting minutes the facility failed to resolve grievances related to dietary concerns for 7 of 20 confidential residents (Residents A, B, C, D, E, F, and G) interviewed on the Transitional Care Unit (TCU). Failure to resolve the resident's concerns in a timely manner resulted in continued dissatisfaction regarding cold food. Findings include: During the afternoons of 10/17/22 and 10/19/22, Residents A, B, C, D, E, F, and G reported food is cold when served. Each resident indicated they had reported this to staff and the food is still cold when served. During the supper meal on 10/19/22 at 6:00 p.m., four residents at one table reported the roast beef and mashed potatoes were cold when delivered. […]