Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Nelson County Health System Care Center during CMS and state inspections, most recent first.
The facility failed to prevent resident-to-resident physical abuse when a cognitively impaired resident with dementia-related behavioral issues, already care planned for aggressive mood fluctuations and a history of physical contact, grabbed and forcefully squeezed another resident’s arm in a hallway and, in a separate episode, yelled and struck another cognitively impaired resident in the face multiple times while they were seated together. In both incidents, the affected residents, who had dementia and other psychiatric diagnoses, reported or were documented as having been physically assaulted, though no injuries were ultimately noted, demonstrating that residents were not kept free from abuse by another resident as required by facility policy.
The facility failed to investigate two separate resident-on-resident altercations involving a cognitively impaired resident with dementia, anxiety, and a care plan noting aggressive mood fluctuations and prior physical contact with others. In the first incident, this resident grabbed and forcefully squeezed another resident’s arm in a hallway after being tapped on the shoulder, but the facility did not complete the interviews and root cause analysis required by its abuse policy. In the second incident, the same resident began yelling, swinging, and striking another resident in the face multiple times while they were sitting and talking; although the assaulted resident had no noted injuries and the aggressor was moved to a quiet area, there is no evidence of a thorough abuse investigation or evaluation of interventions after the initial event.
A resident with a history of dementia, bipolar disorder, and physical aggression physically assaulted another resident on two occasions, including striking and pulling hair, after their wheelchairs became entangled in a common area. Despite existing care plans and hourly monitoring, staff did not prevent these incidents, resulting in physical abuse as defined by facility policy.
A resident with a long-term indwelling urinary catheter on enhanced barrier precautions did not receive care in accordance with infection control policies. A CNA failed to wear a gown during high-contact care, did not perform hand hygiene after glove removal, and improperly rinsed a contaminated collection container, despite facility policies requiring these actions. These lapses were observed during catheter care, resident transfer, and incontinence care.
A resident with dementia and severely impaired cognition exhibited repeated aggressive behaviors towards another resident, including kicking and verbal taunting. Despite having a behavior management plan, the facility failed to effectively control the resident's actions, resulting in multiple incidents of abuse and an unsafe environment. Staff interventions were insufficient, and attempts to transfer the aggressive resident to a more suitable care setting were unsuccessful.
A resident with Alzheimer's and dementia was administered morphine sulfate for anxiety and pain without prior attempts at non-pharmacological interventions or less restrictive medications. The facility lacked a pain management policy, and the resident's care plan did not address pain. Despite quarterly assessments indicating no pain, morphine was given multiple times without proper documentation or justification.
The facility did not submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) for two out of four reporting periods. The PBJ Long-Term Care Facility Policy Manual mandates quarterly submission of direct care staffing and census data. A review of the PBJ Data Staff Report CASPER Report confirmed the missing data for the specified quarters, as verified by an administrative staff member during an interview.
The facility did not review and revise comprehensive care plans for three residents, leading to discrepancies in care. One resident's care plan lacked an intervention for using a gluteal strap during transfers with a mechanical stand lift. Another resident's care plan was not updated to reflect the end of a walking program, causing inconsistencies with the care card used by CNAs. Additionally, a third resident's care plan did not address the use of antidepressant and anticoagulant medications, despite relevant physician's orders and diagnoses. These issues hindered staff's ability to provide appropriate care and ensure resident safety.
The facility did not consistently apply compression stockings for a resident with bilateral lower extremity edema, as per the physician's orders and care plan. Observations showed the resident wearing non-compression stockings or no stockings at all. Additionally, the facility failed to obtain a physician's order for a splint for another resident after hospital discharge, despite the resident's need for the splint due to swelling and pain. The order for the splint was discontinued without proper clarification or updating of the care plan.
The facility did not consistently use prescribed assistive devices and provide adequate supervision during transfers for two residents with mobility and cognitive impairments. For a resident with weakness and dementia, CNAs did not always use the gluteal and leg straps during mechanical stand lift transfers, despite care plan and physician's orders. Similarly, another resident requiring assistance with transfers and toilet use experienced inconsistent adherence to care plan instructions for one or two assists. CNAs made decisions based on the residents' behavior and condition on a given day, leading to potential safety risks.
The facility failed to provide appropriate toileting assistance for two residents, leading to extended periods without care and resulting in injuries and discomfort. Staff misunderstood the residents' needs and did not follow care plans, leaving residents at risk for skin breakdown and other complications.
The facility failed to ensure the safe and secure storage of medications in one medication cart. A nurse left the cart unattended for over eight minutes with six insulin pens/vials on top, and the cart was unlocked and out of view. Facility policy requires the cart to be locked when unattended and medications not to be left on top.
Staff compliance with standard infection control practices, specifically hand hygiene and glove use, was not ensured for several residents. A CNA did not perform hand hygiene before or after providing incontinence care, leading to potential cross-contamination risks. Another CNA failed to change gloves or perform hand hygiene while providing incontinence care, increasing the risk of infection transmission. Additionally, a CNA did not practice hand hygiene after using a stand lift to assist with toileting, touching various surfaces in the resident's room without proper hand hygiene.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. Facility policy on abuse, neglect, mistreatment, and misappropriation of resident property, dated 07/07/21, states that all residents have the right to be free from verbal, sexual, and physical abuse and must not be subject to abuse by anyone, including other residents. Despite this policy, one resident with Alzheimer's disease, restlessness and agitation, anxiety disorder, and severely impaired cognition, who had a care plan noting aggressive mood fluctuations related to dementia and anxiety and a history of physical contact with another resident, physically grabbed, pulled, and squeezed another resident's arm in a hallway incident. The resident whose arm was grabbed had non-Alzheimer's dementia, anxiety disorder, depression, and intact cognition, and later reported that the aggressor was strong and that she had to pull her arm away, though she stated she was not hurt. In a separate incident, the same cognitively impaired resident with dementia-related behavioral issues struck another resident multiple times in the face while they were sitting next to each other and talking. The progress note documented that the aggressor began yelling and swinging, hitting the other resident in the face multiple times. The resident who was hit, who had dementia, anxiety, behavior disturbance, psychotic disorder, and severely impaired cognition, reported at the time that the other resident “just started hitting me in the face” and that she moved away, and no injuries or pain were noted on assessment. Both involved residents in this second incident were described as confused and unable to be interviewed for the facility’s FRI investigation. The facility’s failure to prevent these two episodes of resident-to-resident physical abuse, despite known behavioral risks and a care plan addressing aggressive behavior, resulted in residents not remaining free from abuse as required by facility policy.
Failure to Investigate Resident-on-Resident Abuse Incidents
Penalty
Summary
The facility failed to investigate alleged violations of abuse involving two residents who were physically assaulted by another resident with a known history of aggressive mood fluctuations related to dementia and anxiety. Facility policy on Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property required that the nurse begin an investigation immediately, including root cause analysis and interviews with staff, roommates, family, and visitors. An FRI dated 01/25/26 documented an incident in which one resident grabbed, pulled, and squeezed another resident’s arm in the west hallway. The final investigation note only reflected that the resident whose arm was grabbed reported that the aggressor was strong but that her arm was okay, and later described that she had tapped the aggressor on the shoulder to compliment her sweater, after which the aggressor grabbed her arm hard and she had to pull away. There is no documentation in the report of a comprehensive investigation consistent with facility policy. A second FRI dated 02/02/26 documented that the same aggressive resident began yelling, swinging, and hitting another resident in the face multiple times while they were sitting together and talking. The assaulted resident stated that the aggressor “just started hitting me in the face, so I moved away from her” and suggested the aggressor “needs a shot or something.” Assessment at that time showed no injuries and no pain, and the aggressor was moved to a quiet area. Medical records showed the aggressor had Alzheimer’s disease, restlessness and agitation, anxiety disorder, severely impaired cognition, and a care plan noting aggressive mood fluctuations and a history of physical contact with another resident, with an intervention to maintain distance from others when appropriate for safety. The other involved residents had dementia and anxiety disorders, with one having intact cognition and the other severely impaired cognition. Although both incidents were reported to facility administration and the state agency, the facility did not conduct investigations of the altercations in accordance with its policy, nor did it implement and evaluate appropriate interventions following the first incident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with diagnoses including bipolar disorder, dementia, Parkinson's disease, and schizoaffective disorder exhibited physical aggression towards another resident. The care plan for this resident identified a history of wandering, refusing care, and both verbal and physical aggression, with interventions such as medication administration, positive approaches to care, and seeking additional staff assistance as needed. Despite these measures, the resident physically assaulted another resident on two occasions, first by striking her with a closed fist and then by slapping her and pulling her hair. Both incidents occurred in a common area when the residents' wheelchairs became entangled, and staff intervened to separate them without reported injury. The facility's policy prohibits all forms of abuse, including physical abuse such as hitting and slapping. Documentation showed that the aggressive resident was already on hourly checks due to elopement risk, and the other resident was also monitored hourly for safety following the incidents. The events were confirmed through medical record review, facility-reported incident documentation, and staff interviews, establishing that the facility failed to ensure residents remained free from abuse by not preventing the physical altercations.
Failure to Follow Infection Control Standards for Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for a resident with an indwelling urinary catheter who was on enhanced barrier precautions (EBP). During observation, a certified nurse aide (CNA) entered the resident's room, applied gloves but did not don a gown as required by EBP signage and facility policy. The CNA emptied the urine from the resident's leg bag into a collection container, disposed of the urine in the toilet, and rinsed the contaminated container under the sink faucet in a shared bathroom, contrary to policy which required use of a spray wand. The CNA then removed gloves but did not perform hand hygiene before obtaining equipment from the hallway and preparing for a resident transfer. During the transfer and subsequent incontinence care, the CNA again failed to change gloves between tasks and did not perform hand hygiene after glove removal. The CNA applied skin barrier cream and a clean brief, then handled the resident's nasal cannula and call light without washing hands. These actions were inconsistent with facility policies on hand hygiene, EBP, and catheter care, as confirmed by administrative staff during interview, who stated expectations for glove changes, hand hygiene, use of gowns, and proper cleaning of contaminated containers.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving a resident with severely impaired cognition who exhibited verbal and physical aggressive behaviors towards another resident. The aggressive resident, who has a history of dementia and cognitive decline, was documented to have repeatedly kicked and verbally taunted another resident, leading to multiple incidents of physical and psychosocial harm. Despite having a care plan in place that included interventions to manage the resident's behavior, such as anticipating needs, providing positive interactions, and diverting attention, these measures were insufficient in preventing the aggressive behavior. The incidents were documented over several days, with the aggressive resident repeatedly seeking out and antagonizing the same resident, resulting in physical altercations. Staff interventions included separating the residents and attempting to redirect the aggressive resident, but these efforts were not consistently effective. The facility's records show that the aggressive resident's behavior was escalating, with multiple documented instances of physical aggression and verbal taunting, despite staff attempts to manage the situation. The facility's failure to effectively implement and follow through with the behavior management plan resulted in an unsafe environment for the residents involved. The aggressive resident's behavior was not adequately controlled, leading to repeated incidents of abuse. The facility's inability to secure a transfer for the aggressive resident to a more suitable care environment further contributed to the ongoing risk of harm to other residents.
Failure to Ensure Resident is Free from Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, specifically morphine sulfate, which was administered without proper justification or documentation. The resident, who had diagnoses including Alzheimer's disease, obsessive-compulsive disorder, and dementia with agitation, was given morphine sulfate for anxiety and pain without prior attempts at non-pharmacological interventions or the use of less restrictive medications like acetaminophen. The resident's care plan did not address pain management, and quarterly pain assessments indicated no pain or non-verbal indicators of pain. Despite this, morphine was administered multiple times over a three-day period for anxiety and pain, often without a documented pain rating. The facility did not provide a policy on pain management or opioid use when requested, and the resident's medical record lacked documentation of pain assessments related to the new onset of pain. An administrative nurse confirmed the absence of pain documentation and the failure to use non-pharmacological interventions or less restrictive medications before administering morphine. The facility's actions did not allow the resident to attain or maintain their highest level of practicable well-being, as required by regulations.
Non-Compliance with PBJ Data Submission Requirements
Penalty
Summary
The facility failed to submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) for 2 out of 4 reporting periods. The Electronic Staffing Data Submission PBJ Long-Term Care Facility Policy Manual requires timely and accurate submission of direct care staffing and census data quarterly. Review of the PBJ Data Staff Report CASPER Report indicated that the facility did not submit data for the specified quarters, as confirmed by an administrative staff member during an interview.
Care Plan Review and Revision Deficiencies
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for three sampled residents, leading to deficiencies in care. For Resident #13, the care plan did not include an intervention to use the gluteal strap when transferring the resident with the mechanical stand lift, as observed during toileting and transfers. Resident #25's care plan was not updated to reflect the cessation of the walking program by Physical Therapy, resulting in a discrepancy between the care plan and the resident's current ambulation status noted on the care card used by CNAs. Additionally, Resident #32's care plan did not address the resident's use of antidepressant and anticoagulant medications, despite the presence of related physician's orders and diagnoses of atrial fibrillation and mood disorder. Observations during the survey highlighted instances where the care plans did not accurately reflect the residents' current needs and interventions required for their care. The lack of updated information in the care plans for Residents #13, #25, and #32 hindered the staff's ability to provide appropriate care, communicate effectively, and ensure resident safety. These deficiencies in care planning could potentially impact the quality of care provided to these residents and compromise their well-being.
Inconsistent Adherence to Compression Stocking and Splint Orders
Penalty
Summary
The facility failed to provide appropriate care and services for two sampled residents. For Resident #25, who had bilateral lower extremity edema, the facility did not consistently apply compression stockings as ordered for edema management, as noted in the physician's orders and care plan. Observations on multiple occasions showed the resident wearing non-compression stockings or no stockings at all, indicating a lack of adherence to the prescribed treatment plan. Staff acknowledged the expectation to apply compression stockings as ordered, highlighting a gap in implementation. Regarding Resident #26, who wore a splint to the left hand/wrist due to swelling and pain, the facility did not obtain a physician's order for the splint after the resident returned from the hospital. Despite the resident's reported need for the splint and instructions to wear it at all times, the order for the splint was discontinued on the treatment administration record without proper clarification or updating of the care plan. This failure to secure the necessary order and ensure compliance with the treatment plan raises concerns about the facility's oversight and communication regarding resident care.
Inconsistent Use of Assistive Devices and Supervision During Resident Transfers
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for two sampled residents (#13 and #19). For Resident #13, who had weakness and dementia, CNAs did not consistently use the gluteal strap and leg strap during transfers with a mechanical stand lift, leading to unsafe transfers. Despite the care plan and physician's order specifying the use of these assistive devices, CNAs did not consistently follow these guidelines, citing decisions based on the resident's behavior that day. Similarly, for Resident #19, who required assistance with transfers and toilet use, CNAs did not consistently follow the care plan's instructions for one or two assists, leading to potential risks during ambulation and transfers. The CNAs mentioned making decisions based on the resident's condition that day, indicating a lack of consistent adherence to established protocols.
Failure to Provide Appropriate Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting for two residents who required staff assistance. Resident #8, who has Alzheimer's disease and a history of falls, was supposed to receive supervision-limited assistance with toileting every 2-3 hours. However, the toileting log showed 43 instances where staff did not assist the resident as care planned, with gaps ranging from 3.5 to 14 hours. This lack of assistance led to an incident where the resident fell and sustained injuries, including a broken hand, which required medical attention and an orthopedic consult. Interviews with CNAs revealed a misunderstanding of the resident's need for assistance, as they believed the resident was independent in toileting. Resident #13, who has dementia and is at risk for skin breakdown and falls, required assistance with a mechanical stand lift for toileting every 2-3 hours. The toileting log showed 82 instances where staff failed to assist the resident as care planned, with gaps ranging from 3.5 to 13 hours. Observations revealed that the resident was left in a very wet incontinent product for five hours, causing discomfort and agitation. CNAs attempted to assist the resident but did not follow through when the resident exhibited distress, and they failed to inform the licensed nurse about the resident's inability to use the mechanical lift and the lack of toileting. The facility did not provide a policy related to the toileting of residents, which contributed to the deficiencies observed. The lack of adherence to care plans and failure to provide timely assistance with toileting placed the residents at risk for skin breakdown, poor hygiene, and other complications. Interviews with staff and record reviews confirmed the lapses in care, highlighting the need for better communication and adherence to care plans to ensure resident safety and dignity.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications in one medication cart. During an observation, a staff nurse left the medication cart unattended for over eight minutes with six insulin pens/vials on top of the cart. The cart remained unlocked in the hallway and out of the nurse's view. The facility's policy, revised in 2016, requires that the medication cart be locked when unattended and that medications should not be left on top of the cart. An administrative nurse confirmed that staff are expected to secure medications within the cart and lock it when out of eyesight.
Infection Control Practices: Hand Hygiene and Glove Use Deficiencies
Penalty
Summary
The facility failed to ensure staff compliance with standard infection control practices, specifically related to hand hygiene and glove use, for several residents as observed during the survey. In one instance, a certified nurse aide (CNA) did not perform hand hygiene before or after providing incontinence care to Resident #16, leading to potential cross-contamination risks. Another CNA failed to change gloves or perform hand hygiene while providing incontinence care to Resident #1, further increasing the risk of infection transmission. Additionally, a CNA did not practice hand hygiene after using a stand lift to assist Resident #6 with toileting, touching various surfaces in the resident's room without proper hand hygiene.
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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 Mcville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aneta Parkview Health Ctr | 10.6 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Lakota | 20.7 mi | ★★★★★ | 0 | 0 |
| Griggs County Care Center | 22.9 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Larimore | 27.6 mi | — | 28 | 0 |
| Northwood Deaconess Health Cnt | 28.1 mi | — | 0 | 0 |
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