SNF
NELSON COUNTY HEALTH SYSTEM CARE CENTER
CCN: 355052 · MCVILLE, ND 58254 · Nelson County
Abuse citation flag
Overview
- Address
- 108 E NYHUS AVE, MCVILLE, ND 58254
- Phone
- 7013224314
- Certified beds
- 35
- Avg daily residents
- 29 (83% of beds filled)
- Ownership
- Government (city)
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1980-04-01
- Setting
- Rural
3 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 4.35 | 3.35 | 5.01 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.81 | 0.59 | 0.94 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.64 | 0.74 | 0.74 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.90 | 2.02 | 3.34 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.45 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.00 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.53
hrs / resident / day
RN (weekend)
0.38
hrs / resident / day
Total nurse (adjusted, weekend)
4.07
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
47.5%
annual
RN turnover
0.0%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.19
higher acuity than avg
Case-Mix Index Ratio
0.86
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-04-01 | 2 | 1 | 1 | 8 | 1 | 8 |
| Cycle 2/3 (prior) | 2024-03-21 | 11 | 7 | 4 | 72 | 1 | 72 |
Total weighted health score
24.0
lower is better
Infection-control citations
0
last cycle
Deficiencies (13)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
12 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | 2025-06-23 | 2025-06-23 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2025-04-01 | 2025-05-06 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | 2024-11-26 | 2025-01-06 |
| 0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D | 2024-11-26 | 2025-02-24 |
| 0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | 2024-03-21 | 2024-04-18 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2024-03-21 | 2024-04-29 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2024-03-21 | 2024-04-29 |
| 0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | 2024-03-21 | 2024-04-29 |
| 0761 | 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. | D | 2024-03-21 | 2024-04-29 |
| 0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F | 2024-03-21 | 2024-04-29 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2024-03-21 | 2024-04-29 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2023-03-15 | 2023-04-04 |
| 0888 | Ensure staff are vaccinated for COVID-19 | D | 2023-03-15 | 2023-03-20 |
Penalties (1)
Fines issued
1
last 3 years
Total fines
$36,855
| Date | Type | Fine amount |
|---|---|---|
| 2024-11-26 | Fine | $36,855 |
Source: CMS Nursing Home Penalties.
Ownership & Corporate Structure
Owner / manager organizations (1)
| Organization | Role | Association |
|---|---|---|
| NELSON COUNTY HEALTH SYSTEM | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 01/01/2010 |
Owner / manager individuals (9)
| Name | Role | Association |
|---|---|---|
| FORDE, STEVEN | OPERATIONAL/MANAGERIAL CONTROL | since 09/19/2016 |
| BERG, IVAN | CORPORATE DIRECTOR | since 11/06/2011 |
| JENSEN, BRANDON | CORPORATE DIRECTOR | since 11/07/2013 |
| LUNDEBY, BRANDON | CORPORATE DIRECTOR | since 11/06/2011 |
| OXTON, RANAE | CORPORATE DIRECTOR | since 11/06/2011 |
| STEIN, HEATHER | CORPORATE DIRECTOR | since 11/24/2014 |
| TWETE, ANGELA | CORPORATE DIRECTOR | since 11/24/2014 |
| TWETE, JUDITH | CORPORATE DIRECTOR | since 11/06/2011 |
| SWENSON, CATHERINE | W-2 MANAGING EMPLOYEE | since 10/14/2015 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- Yes — last 2 cycles
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 99 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Provider Information | Abuse Icon | Y | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.73557 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 3.34128 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.93779 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 5.01465 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 4.06879 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 29.1 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.74262 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.01828 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.58535 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.34625 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 2.94937 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | — | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | — | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | — | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | — | Chain Average Staffing Rating |
| Provider Information | Chain ID | — | Chain ID |
| Provider Information | Chain Name | — | Chain Name |
| Provider Information | City/Town | MCVILLE | City/Town |
| Provider Information | CMS Certification Number (CCN) | 355052 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Nelson | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1980-04-01 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 2 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 47.7686 | Latitude |
| Provider Information | Legal Business Name | NELSON COUNTY HEALTH SYSTEM | Legal Business Name |
| Provider Information | Location | 108 E NYHUS AVE,MCVILLE,ND,58254 | Location |
| Provider Information | Long-Stay QM Rating | 2 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -98.177 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 35 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | 0 | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | — | Number of Facilities in Chain |
| Provider Information | Number of Fines | 1 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.18543 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.86047 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 3 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Government - City | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 108 E NYHUS AVE | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | NELSON COUNTY HEALTH SYSTEM CARE CENTER | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 310 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 2 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 8 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 1 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 1 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-04-01 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 8 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 2 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 7 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-03-21 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 72 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 4 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 72 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 11 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.37814 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 0.0 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.45030 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.63752 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.89587 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.00000 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.81278 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 4.34617 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | — | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | 2 | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 5 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | ND | State |
| Provider Information | Telephone Number | 7013224314 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 36855.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.52641 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 1 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 47.5 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 24.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | N | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 58254 | ZIP Code |