Federal inspection record · CMS data as of October 1, 2026
Nelson County Health System Care Center
108 E Nyhus Ave, Mcville, ND · (701) 322-4314
- Cited for abuse (CMS abuse icon)
- Certified beds
- 35
- Residents per day
- 32
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 1, 1980
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in North Dakota.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★−1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among North Dakota homes
Nelson County Health System Care Center carries 23 inspection points. That is fewer than 65% of North Dakota's 71 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in North Dakota: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–10 pts
- 4★ 10–23 pts
- 3★ 23–42.5 pts
- 2★ 42.5–76 pts
- 1★ over 76 pts
Bars show every rated home in North Dakota by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
15 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Quality of Life and Care4D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Freedom from Abuse, Neglect, and Exploitation4D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Respond appropriately to all alleged violations.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Infection Control3E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Administration1F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Resident Assessment and Care Planning1D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Pharmacy Service1D
- D
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.
Inspection history
2026-06-10
4 health deficiencies · 3 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2025-04-01
4 health deficiencies · 4 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2024-03-21
7 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 20 min of nursing staff time a day, 47 min of it from a registered nurse.
This home
4 h 20 min
North Dakota average
4 h 28 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 56% of nursing staff and 50% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$36,855 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-11-26 | Fine | $36,855 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.2 pts worse | 1.7 | 1.5 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.3 pts worse | 3.1 | 1.8 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.8 pts worse | 96.7% | 98.5% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.7 pts better | 100.0% | 98.3% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury5.6 pts worse | 10.7% | 5.1% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.2 pts better | 0.0% | 4.2% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.2 pts better | 4.6% | 5.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication8.3 pts better | 9.3% | 17.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3 pts better | 19.8% | 22.8% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.2 pts better | 0.0% | 0.2% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened3.3 pts better | 13.0% | 16.3% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.8 pts worse | 27.7% | 19.9% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladderAbout the same | 1.4% | 1.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2 pts worse | 4.5% | 2.5% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence6.5 pts worse | 30.5% | 24.0% | 18.3% |
| Percentage of long-stay residents with pressure ulcers4.1 pts worse | 8.8% | 4.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.7 pts better | 95.0% | 91.3% | 82.3% |
·
Who owns and runs it
10 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Nelson County Health System | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Berg, Ivan | Corporate Director · Individual | 0% | 1 facilities |
| Forde, Steven | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Jensen, Brandon | Corporate Director · Individual | 0% | 1 facilities |
| Lundeby, Brandon | Corporate Director · Individual | 0% | 1 facilities |
| Oxton, Ranae | Corporate Director · Individual | 0% | 1 facilities |
| Stein, Heather | Corporate Director · Individual | 0% | 1 facilities |
| Swenson, Catherine | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Twete, Angela | Corporate Director · Individual | 0% | 1 facilities |
| Twete, Judith | Corporate Director · Individual | 0% | 1 facilities |
·
Fire safety
14 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke7F
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Properly provide smoke detection systems in areas open to corridors.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly provide smoke detection systems in areas open to corridors.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
Egress3F
- F
Install emergency lighting that can last at least 1 1/2 hours.
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F
Install emergency lighting that can last at least 1 1/2 hours.
Gas, Vacuum, and Electrical Systems3F
- F
Ensure that testing and maintenance of electrical equipment is performed.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Miscellaneous1E
- E
Have simulated fire drills held at unexpected times.
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Other homes nearby
-
Aneta Parkview Health Ctr
Aneta, ND
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 19 min
- Fines
- $0
-
Good Samaritan Society - Lakota
Lakota, ND · Good Samaritan Society
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 57 min
- Fines
- $48,445
-
Griggs County Care Center
Cooperstown, ND
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 39 min
- Fines
- $0