CareSentinel

Federal Nursing-Home Survey Record

Neilson Place

CCN 245039 · 1000 ANNE STREET NORTHWEST, BEMIDJI, MN, 56601 · Operated within the SANFORD HEALTH chain

Does Neilson Place have a federal violation or abuse history?

According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Neilson Place (CCN 245039), in BEMIDJI, MN, has federal inspection findings on its record. CMS currently displays its federal abuse icon for this facility — a flag CMS assigns under its own published methodology for abuse-related citations (deficiency tag F600 and related). In its current inspection cycle, CMS cited the facility for 11 deficiencies; the most serious carries scope/severity G on CMS's A–L scale, a level CMS classifies as actual harm. The most recent federal survey on file is dated 2026-03-05. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $55,255 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

The Federal Record

CMS has flagged this facility with its federal abuse icon.

Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Federal Abuse Icon

Federal abuse icon on file

CMS displays its abuse icon for facilities it has cited for resident abuse under its own published methodology (deficiency tag F600 and related). This is the government's own flag, restated here.

Scope & Severity — current cycle

ANo Harm
BNo Harm
CNo Harm
DPotential
EPotential
FPotential
GActual Harm
HActual Harm
IActual Harm
JImm. Jeopardy
KImm. Jeopardy
LImm. Jeopardy

CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations, as on file with federal regulators (CMS).

Civil money penalties on file

$55,255

CMS has $55,255 in civil money penalties on file against this facility.

Overall CMS star rating: this facility vs the CMS-published state average

This facility: 1  ·  CMS state average: 3.2

Side-by-side with the CMS-published Overall CMS star rating for this state. This is the government's own published state average — not a CareSentinel-computed figure or delta.

Deficiency timeline — full federal history

2026-03-05
CURRENT CYCLE
F812S/S E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

2026-03-05
CURRENT CYCLE
F880S/S E

Provide and implement an infection prevention and control program.

2026-03-05
CURRENT CYCLE
F658S/S D

Ensure services provided by the nursing facility meet professional standards of quality.

2026-03-05
CURRENT CYCLE
F677S/S D

Provide care and assistance to perform activities of daily living for any resident who is unable.

2026-03-05
CURRENT CYCLE
F605S/S D

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

2026-03-05
CURRENT CYCLE
F700S/S D

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

2026-03-05
CURRENT CYCLE
F688S/S D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

2026-03-05
CURRENT CYCLE
F637S/S D

Assess the resident when there is a significant change in condition

2025-12-09
CURRENT CYCLE
F689S/S G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2025-07-02
CURRENT CYCLE
F603S/S G

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

2025-07-02
CURRENT CYCLE
F557S/S D

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

2025-04-04
HISTORICAL
F880S/S D

Provide and implement an infection prevention and control program.

2025-02-25
HISTORICAL
F656S/S D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2025-02-25
HISTORICAL
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2024-12-20
HISTORICAL
F689S/S G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2024-12-05
HISTORICAL
F812S/S F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

2024-12-05
HISTORICAL
F880S/S F

Provide and implement an infection prevention and control program.

2024-12-05
HISTORICAL
F883S/S D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

2024-12-05
HISTORICAL
F677S/S D

Provide care and assistance to perform activities of daily living for any resident who is unable.

2024-12-05
HISTORICAL
F692S/S D

Provide enough food/fluids to maintain a resident's health.

2024-12-05
HISTORICAL
F732S/S D

Post nurse staffing information every day.

2024-12-05
HISTORICAL
F756S/S D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

2024-12-05
HISTORICAL
F758S/S D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

2024-12-05
HISTORICAL
F759S/S D

Ensure medication error rates are not 5 percent or greater.

2024-12-05
HISTORICAL
F803S/S D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

2024-09-27
HISTORICAL
F678S/S J

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

2024-07-02
HISTORICAL
F740S/S D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

2024-07-02
HISTORICAL
F760S/S D

Ensure that residents are free from significant medication errors.

2024-02-29
HISTORICAL
F686S/S G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2024-02-29
HISTORICAL
F689S/S G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2024-02-29
HISTORICAL
F610S/S D

Respond appropriately to all alleged violations.

2024-02-29
HISTORICAL
F585S/S D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

2024-02-29
HISTORICAL
F609S/S D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2023-11-09
HISTORICAL
F610S/S D

Respond appropriately to all alleged violations.

2023-11-09
HISTORICAL
F600S/S D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

2023-11-09
HISTORICAL
F609S/S D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2023-10-25
HISTORICAL
F880S/S F

Provide and implement an infection prevention and control program.

2023-10-25
HISTORICAL
F804S/S E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

2023-10-25
HISTORICAL
F550S/S D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

2023-10-25
HISTORICAL
F578S/S D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

2023-10-25
HISTORICAL
F803S/S D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

2023-10-25
HISTORICAL
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2023-10-25
HISTORICAL
F679S/S D

Provide activities to meet all resident's needs.

2023-10-25
HISTORICAL
F607S/S C

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

2023-10-19
HISTORICAL
F609S/S E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2023-10-19
HISTORICAL
F610S/S E

Respond appropriately to all alleged violations.

2023-10-19
HISTORICAL
F689S/S D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Each citation below is a federal survey finding, dated and labeled with its CMS deficiency tag, as on file with federal regulators (CMS). Older inspection cycles are de-emphasized; only the most recent cycle is current.

Document what happened

Were you or a loved one harmed at Neilson Place?

Share a few details to put your inquiry on file. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. As qualified attorneys join our network in your area, one may reach out — we can’t guarantee contact yet, so we encourage you to consult a qualified attorney promptly on your own as well. There is no cost, and your information is handled with care.

Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Step 1 of 3 · What happened

Your relationship to the resident
What happened? Select all that apply.

Physical injury

Skin & wounds

Medical & clinical

Safety & abuse

Loss

Something else

The resident is…