NEILSON PLACE

CCN 245039 · SANFORD HEALTH OF NORTHERN MINNESOTA · Non profit - Corporation · SANFORD HEALTH chain · 78 certified beds · Beltrami · MN


NEILSON PLACE is a 78-bed nursing home in BEMIDJI, Minnesota. CMS has certified it for Medicare and Medicaid since 1979-01-01. It averages 71.0 residents a day.

What harm was found in the violations cited at NEILSON PLACE?

CMS lists 47 health-inspection deficiencies for NEILSON PLACE, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is J; the most recent health inspection was 2026-03-05.

Survey dateTagDeficiencySeverity
2026-03-05F0812, F0880Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program.E
2026-03-05F0605, F0637, F0658, F0677, F0688, F0700Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. / Assess the resident when there is a significant change in condition / Ensure services provided by the nursing facility meet professional standards of quality. / Provide care and assistance to perform activities of daily living for any resident who is unable. / 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. / 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.D
2025-12-09F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2025-07-02F0603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).G
2025-07-02F0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.D
2025-04-04F0880Provide and implement an infection prevention and control program.D
2025-02-25F0656, F0684Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide appropriate treatment and care according to orders, resident’s preferences and goals.D
2024-12-20F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2024-12-05F0812, F0880Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program.F
2024-12-05F0677, F0692, F0732, F0756, F0758, F0759, F0803, F0883Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide enough food/fluids to maintain a resident's health. / Post nurse staffing information every day. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / 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. / Ensure medication error rates are not 5 percent or greater. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations.D
2024-09-27F0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.J
2024-07-02F0740, F0760Ensure each resident must receive and the facility must provide necessary behavioral health care and services. / Ensure that residents are free from significant medication errors.D
2024-02-29F0686, F0689Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2024-02-29F0585, F0609, F0610Honor 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations.D
2023-11-09F0600, F0609, F0610Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations.D
2023-10-25F0880Provide and implement an infection prevention and control program.F
2023-10-25F0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.E
2023-10-25F0550, F0578, F0679, F0684, F0803Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / 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. / Provide activities to meet all resident's needs. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / 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.D
2023-10-25F0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.C
2023-10-19F0609, F0610Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations.E
2023-10-19F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D

Why was NEILSON PLACE fined 3 times?

DateTypeAmount
2025-12-09Fine$17,345
2024-09-27Fine$14,433
2024-02-29Fine$14,137

How is NEILSON PLACE staffed relative to the MN average?

MeasureThis facilityMN average
Total nurse staffing hours per resident per day3.804774.19318
Total nursing staff turnover (%)55.442.2
Average number of residents per day71.060.3

Who owns NEILSON PLACE, and what chain is it in?

NEILSON PLACE is registered with CMS as Non profit - Corporation, operates under the legal business name SANFORD HEALTH OF NORTHERN MINNESOTA and belongs to the SANFORD HEALTH chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTSANFORD NORTHsince 05/01/2014
5% OR GREATER INDIRECT OWNERSHIP INTERESTSANFORDsince 05/01/2014
W-2 MANAGING EMPLOYEEDULSKI, KARIN, GASSEN, WILLIAM, MARLETTE, WILLIAM, MORRISON, TONY, MUNSON, JOLYN, SWENSON, STEPHANIEsince 02/01/1991
CORPORATE DIRECTORCAIN, JAMES, ENGBRECHT, WESLEY, GASSEN, WILLIAM, GULSVIG, NEIL, JACOBS, DONALD, LUNDEEN, MARK, MOLBERT, LAURIS, NORTH, ANDREW, TEIKEN, BRENT, VENTLING-HERRMANN, MARNIEsince 01/01/2014
CORPORATE OFFICERGASSEN, WILLIAM, MARLETTE, WILLIAM, MORRISON, TONYsince 02/01/1991

Were you or a family member harmed at NEILSON PLACE?