Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
NELSON COUNTY HEALTH SYSTEM CARE CENTER
MCVILLE, ND · 35 certified beds · Last Life Safety survey April 1, 2025
CMS Certification Number 355052 · first certified April 1980
Ownership
Independently operated (no chain recorded by CMS) · Government - City
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within ND
14 citations — more than 97% of the 72 certified nursing homes in ND. Compared within ND rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2026 to June 2026), and past the point by which nine in ten ND facilities have been surveyed. This facility’s last Life Safety survey was April 2025. Facilities in ND are typically surveyed 12–14 months after the last one (median 13), measured over 116 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in ND, and nationally. Surveyors differ markedly between states, so the ND figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in ND | 2 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 15, 2023 | 3 |
| March 21, 2024 | 7 |
| April 1, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 3 | 2025-04-01 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-04-01 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-04-01 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2024-03-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-04-01 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-03-21 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2024-03-21 |
What the citations cover
- Smoke Deficiencies 7
- Egress Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Egress Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 1, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 1, 2025) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (May 7, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 1, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 1, 2025) |
March 21, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 20, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 20, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 20, 2024) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (May 20, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 20, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 20, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 20, 2024) |
March 15, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 27, 2023) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (March 27, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 27, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.