Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mckenzie County Healthcare Systems Long Term Care during CMS and state inspections, most recent first.
Hand hygiene and EBP were not followed during resident care. A CNA failed to perform hand hygiene after removing soiled gloves before placing an oxygen cannula on a resident, and other CNAs did not clean their hands between glove changes during brief changes and perineal care. In another instance, a CNA entered the room of a resident with a history of MRSA and applied compression stockings and shoes without first using the gown and gloves required by the facility’s EBP policy.
A resident had an unlabeled bottle of Calm Forte, a sleep aid, observed at the bedside, but the record lacked a self-administration assessment, a physician order to self-administer meds, and an order for the medication. A nurse confirmed the facility had not completed the assessment and was unaware of the medication in the room, and an administrative nurse confirmed the missing assessment and order.
A resident with anxiety received a PRN anti-anxiety medication order for lorazepam that was continued beyond the 14-day limit without documented reevaluation for continued use. Facility policy required PRN psychotropic orders to be limited in duration unless the prescriber documented the rationale and duration for extension, and an administrative nurse confirmed the lapse.
A resident with COPD was observed on survey with continuous O2 via nasal cannula at 2 L, but the medical record did not contain a physician order for oxygen. The care plan noted a need for O2 therapy at 2-3 L to keep sats above 92%, and an administrative nurse confirmed the missing order.
The facility failed to provide written transfer notices to residents or their representatives for hospital transfers. Medical records for several residents showed transfers without evidence of notice. An administrative staff member confirmed the absence of a Hospital Transfer policy and acknowledged the oversight.
The facility failed to provide bed hold notices to residents transferred to the hospital, as required by its policy. A review of medical records and staff interviews revealed that several residents did not receive written information about bed hold policies prior to their hospital transfers. An administrative staff member confirmed the absence of these notices.
A facility failed to update a resident's care plan following changes in their medical status. The resident's Foley catheter was removed, and they required maximum assistance for transfers, yet the care plan inaccurately stated that the resident had a Foley catheter and ambulated independently. This discrepancy was confirmed by an administrative staff member, highlighting a failure to ensure continuity of care.
Hand Hygiene and EBP Not Followed During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards related to hand hygiene and enhanced barrier precautions for 4 of 5 sampled residents observed during care. The facility policies stated that gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them. During observation, a CNA caring for Resident #15 applied a gown and gloves, assisted the resident from the toilet, performed perineal care, and helped the resident to a recliner, then removed soiled gloves and placed the oxygen cannula in the resident’s nose without performing hand hygiene first. An administrative staff member later confirmed that hand hygiene was expected after glove removal and before touching other items. Additional observations showed a CNA completing a brief change for Resident #7 and failing to perform hand hygiene between glove changes after cleansing the perineal area and before continuing care. For Resident #28, a CNA performed perineal care after an incontinent bowel movement, changed gloves, applied skin barrier cream, changed gloves again, and then transferred the resident to a recliner and positioned items within reach without hand hygiene between glove changes. For Resident #1, who had a history of MRSA and whose care plan stated the resident was on enhanced barrier precautions related to that history, a CNA entered the room and applied compression stockings and shoes without first applying a gown and gloves as required by the facility’s EBP policy.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess Resident #5 for self-administration of medications even though an unlabeled bottle of Calm Forte, a sleep aid, was observed on the top of a bedside shelf in the resident’s room on all days of survey. Review of the medical record showed no assessment and no physician’s order authorizing Resident #5 to self-administer medications, and there were also no orders for Calm Forte. The facility policy stated that a resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely. During interview, a nurse confirmed the facility had not completed a self-administration assessment and was unaware of the medication in the room, and an administrative nurse later confirmed the assessment and physician’s order were not obtained.
Unnecessary PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident #22 remained free from unnecessary psychotropic medication use when the resident received a PRN anti-anxiety medication, lorazepam 0.25 mg every three hours as needed for anxiety, without the order being limited to 14 days or reevaluated for continued use. The resident’s diagnoses included anxiety. The physician’s order was written on 05/23/25 and was discontinued on 06/13/25, 21 days later. Facility policy titled Use of Psychotropic Medications stated that PRN orders for psychotropic drugs are to be used only when necessary and for a limited duration, and that if a PRN order is extended beyond 14 days, the prescribing practitioner must document the rationale and duration in the medical record. During interview, an administrative nurse confirmed staff failed to ensure the PRN lorazepam order was limited to 14 days and reevaluated for continued use.
Missing physician order for oxygen therapy
Penalty
Summary
Respiratory care was not provided consistent with professional standards of practice for one sampled resident receiving oxygen by nasal cannula. The facility policy for oxygen administration stated that staff should check physician's orders for liter flow and method of administration, but Resident #15 was observed on all days of survey with continuous oxygen in place via nasal cannula at 2 L. Resident #15's record showed diagnoses including COPD and a care plan noting a need for oxygen therapy with oxygen via nasal prongs/mask at 2-3 L to keep saturations above 92%, but the medical record did not contain a physician's order to administer oxygen. An administrative nurse confirmed during interview that the record lacked a physician's order for oxygen administration.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written notice of transfer to the resident or the resident's representative for five sampled residents who were transferred to the hospital. This deficiency was identified through a review of medical records and staff interviews. The records for Residents #3, #5, #10, #23, and #28 showed hospital transfers on various dates, but lacked evidence of a written transfer notice being provided. During interviews, an administrative staff member confirmed that the facility does not have a Hospital Transfer policy and acknowledged the failure to complete a hospital transfer notice for the residents.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide a bed hold notice upon transfer to the hospital for five sampled residents. This deficiency was identified through a review of the facility's policy, medical records, and staff interviews. The facility's policy, dated April 17, 2024, mandates that written information regarding bed hold policies be provided to residents or their representatives prior to hospital transfers. However, the medical records of the residents transferred to the hospital on various dates lacked evidence of such notices. During an interview, an administrative staff member confirmed the absence of written bed hold notices for these residents.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to review and revise the care plan for one of the sampled residents, identified as Resident #3. According to the facility's policy, comprehensive care plans should be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. However, a review of Resident #3's medical record revealed discrepancies between the care plan and the resident's current medical status. A progress note indicated that the resident's Foley catheter was removed, and the quarterly MDS assessment noted that the resident required maximum assistance for transfers, was not toileted, and no ambulation was attempted. Despite these changes, the care plan still inaccurately reflected that the resident had a Foley catheter and ambulated independently. An administrative staff member confirmed the failure to update the care plan, which limited the staff's ability to communicate the resident's needs and ensure continuity of care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Watford City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Lutheran Nursing & Rehabilitation Center | 29.6 mi | ★★★★★ | 14 | 0 |
| Hill Top Home Of Comfort Inc | 38.4 mi | ★★★★★ | 3 | 0 |
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