Nelson County Health System Care Center
Mcville, Nelson County, North Dakota · CCN 355052 · Government (City) · not part of a chain
CMS rates Nelson County Health System Care Center 2 of 5 overall as of August 2026. 35 certified beds, 32 residents a day on average. 15 citations on record from the current inspection cycles, 1 involving actual harm; 1 fine totalling $36,855.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★★★★ 5 of 5 |
| Quality measures | ★☆☆☆☆ 1 of 5 |
| Quality: long-stay / short-stay | 1 / — of 5 |
Staffing
| Total nurse staffing | 4.06638 hours per resident per day |
|---|---|
| Registered nurses | 0.69668 hours per resident per day |
| Weekend total | 3.44902 hours per resident per day |
| Nursing staff turnover | 51.2% (registered nurses 16.7%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-29 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-01 |
| 2026-04-29 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-01 |
| 2025-06-23 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2025-06-23 |
| 2025-04-01 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-06 |
| 2024-11-26 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-01-06 |
| 2024-11-26 complaint survey |
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-24 |
| 2024-03-21 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · tag F0851 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-04-29 |
| 2024-03-21 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-18 |
| 2024-03-21 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-29 |
| 2024-03-21 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-29 |
| 2024-03-21 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-29 |
| 2024-03-21 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-29 |
| 2024-03-21 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-29 |
| 2023-03-15 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-04 |
| 2023-03-15 | Ensure staff are vaccinated for COVID-19 Infection Control Deficiencies · tag F0888 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-11-26 | Fine | $36,855 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Nelson County Health System Organization | 5% or greater direct ownership interest | 100% | 2010-01-01 |
| Berg, Ivan Individual | corporate director | — | 2011-11-06 |
| Jensen, Brandon Individual | corporate director | — | 2013-11-07 |
| Lundeby, Brandon Individual | corporate director | — | 2011-11-06 |
| Oxton, Ranae Individual | corporate director | — | 2011-11-06 |
| Stein, Heather Individual | corporate director | — | 2014-11-24 |
| Twete, Angela Individual | corporate director | — | 2014-11-24 |
| Twete, Judith Individual | corporate director | — | 2011-11-06 |
| Forde, Steven Individual | operational/managerial control | — | 2016-09-19 |
| Swenson, Catherine Individual | w-2 managing employee | — | 2015-10-14 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Nelson County Health System Care Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Nelson County.