Nursing homeActive
Nelson County Health System Care Center
108 E Nyhus Ave, Mcville, ND 58254701322431435 certified beds · 32 residentsGovernment - CityMedicare and Medicaid
Surveys on file
6
since 2023
Deficiencies
15
● 0● 14● 1
Penalties · 3 yrs
$36,855
1 fine
Last survey
2026-04-29
Complaint
CMS overall
2 / 5
stars as published by CMS
CMS overall 2/5
Health 2
Staffing 5
Quality 1
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · North Dakota Department of Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-04-29 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-06-23 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-04-01 | Standard | 010 | CMS-2567 (Care Compare) | — |
| 2024-11-26 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2024-03-21 | Standard | 070 | CMS-2567 (Care Compare) | — |
| 2023-03-15 | Standard | 020 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · North Dakota Department of Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-01Record 355052-20260429-F600
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-01Record 355052-20260429-F610
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-23Record 355052-20250623-F600
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-06Record 355052-20250401-F880
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-01-06Record 355052-20241126-F600
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-24Record 355052-20241126-F605
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-18Record 355052-20240321-F657
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-29Record 355052-20240321-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-29Record 355052-20240321-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-29Record 355052-20240321-F690
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-29Record 355052-20240321-F761
F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-29Record 355052-20240321-F851
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-29Record 355052-20240321-F880
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-04Record 355052-20230315-F609
F888Ensure staff are vaccinated for COVID-19Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-20Record 355052-20230315-F888
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-11-26 | Civil money penalty | $36,855 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.70
Facility
North Dakota
National
North Dakota 0.93 · National 0.69
Total nurse hours per resident day4.07
Facility
North Dakota
National
North Dakota 4.42 · National 3.86
Weekend total nurse hours3.45
Facility
North Dakota
National
North Dakota 3.80 · National 3.42
Total nursing staff turnover51%
Facility
North Dakota
National
North Dakota 49% · National 46%
Registered nurse turnover17%
Facility
North Dakota
National
North Dakota 40% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | North Dakota | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 8.9% | 4.9% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 10.0% | 5.1% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 21.0% | 22.7% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 4.6% | 2.6% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.2% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 28.2% | 19.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 5.7% | 5.8% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 9.5% | 17.4% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Nelson County Health System Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Forde, Steven Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Berg, Ivan Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Jensen, Brandon Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Lundeby, Brandon Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Oxton, Ranae Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Stein, Heather Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Swenson, Catherine Individual | W-2 MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
| Twete, Angela Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Twete, Judith Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or North Dakota.
No county cost figures on file for Nelson.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Aneta Parkview Health Ctr Aneta | 10.6 mi | 2026-01-28 | 040 |
| Good Samaritan Society - Lakota Lakota | 20.7 mi | 2026-06-16 | 1222 |
| Griggs County Care Center Cooperstown | 22.9 mi | 2025-08-06 | 041 |
| Good Samaritan Society - Larimore Larimore | 27.6 mi | 2026-05-19 | 1453 |
| Good Samaritan Society - Park River Park River | 44.5 mi | 2025-12-04 | 0260 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |