Nelson County Health System Care Center
Mcville, North Dakota · CCN 355052
18 surveys since 2011, 3 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 88
- Surveys
- 18
- Harm or worse
- 3
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 35
- Ownership
- Non profit - Other
- Chain
- Independent
- County
- Nelson · rural
- Medicare-certified since
- 1980
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 5
- Quality measures
- 1
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 42 not-for-profit facilities with fewer than 66 beds in North Dakota.
Last survey on record
Jun 10, 2026
152 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.07 | 4.29 |
| Registered-nurse hours per resident day | 0.70 | — |
| Annual nurse turnover | 51.2% | 50.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $36,855 across 1 penalty
- Abuse icon
- Flagged by CMS on Care Compare
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G15.9% | H— | I— |
| No harm, potential for more than minimal | D1482.4% | E15.9% | F15.9% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6003×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F8803×
Provide and implement an infection prevention and control program.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6051×
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- F6091×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
In the surveyor’s words
From the most serious findings on record at Nelson County Health System Care Center, in the surveyor’s own words.
- Actual harm, isolatedF600Nov 26, 2024
Based on observation, record review, review of the facility reported incident, review of facility policy, and staff interviews the facility failed to ensure residents remained free from abuse from 1 of 1 sampled resident (Resident #1) who displayed verbal and physical behaviors towards residents. Failure to provide necessary services to protect residents from abuse resulted in physical and psychosocial harm. Findings include: Review of the facility policy titled Abuse Prohibition Policy occurred on 11/26/24. This policy, dated July 2021, stated, . Residents must not be subjected to abuse by anyone, including, but not limited to . other residents . Review of the facility reported incident identified on 11/02/24 at 7:30 p.m. […]
- No harm, potential for more than minimal, widespreadF851Mar 21, 2024
Based on review of the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Long-Term Care Facility Policy Manual and staff interview the facility failed to submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission PBJ for 2 of 4 reporting periods. Failure to submit direct care staffing information may result in inaccurate representation of the level of staff in the facility which can impact the quality of care delivered. Findings include: The June 2022, version 2.6 Electronic Staffing Data Submission Payroll-Based Journal (PBJ), pages 1-3, stated, . Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. […]
- No harm, potential for more than minimal, patternF880Jun 10, 2026
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 7 sampled residents (Resident #1, #3 #5, #6, and #16) and one supplemental resident (Resident #20) observed during cares. Failure to practice infection control standards related to transmission based precautions (TBP), enhanced barrier precautions (EBP), and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled [NAME] County Health System Care Center Enhanced Barrier Precautions occurred on 06/10/26. This policy, dated April 2025, stated, . […]
- No harm, potential for more than minimal, patternF801Oct 20, 2021
Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#9) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 10/20/21 at 12:54 p.m., a dietary manager (#9) stated she started the certified dietary manager's (CDM) course in March 2020 and has not yet completed the course. […]
- No harm, potential for more than minimal, patternF880Oct 20, 2021
Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control standards for 4 of 9 sampled residents (Resident #9, #16, #20, and #22) observed during cares. Failure to follow infection control practices for hand hygiene and glove use related to treatments and perineal care has the potential to spread infection from one body site to another and within the facility. Findings include: Review of the facility policy/procedure titled DRESSING CHANGE - NON-STERILE occurred on 10/20/21. […]
Read 22 findings in full →The most serious and the most recent: 22 of 88 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 10, 2026Standard2 findings
- Apr 29, 2026Complaint2 findings
- Jun 23, 2025Complaint1 finding
- Apr 1, 2025Standard1 finding
- Nov 26, 2024Complaint3 findings · 1 harm
- Mar 21, 2024Standard7 findings
- Mar 15, 2023Standard and complaint2 findings
- Oct 20, 2021Standard6 findings
Show the 10 earlier surveys
- Jan 15, 2020Standard4 findings
- Dec 19, 2018Standard7 findings
- Jan 18, 2018Standard6 findings
- Nov 9, 2016Standard7 findings
- Dec 30, 2015Standard4 findings
- Dec 18, 2014Standard10 findings
- Jan 23, 2014Standard6 findings
- Jan 16, 2013—4 findings · 1 harm
- Feb 1, 2012—6 findings
- Feb 10, 2011—10 findings · 1 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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