Public Record
Neilson Place
Operated by Sanford Health
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 78
- Avg. residents per day
- 71.8
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 52
- Fire safety findings
- 21
- Inspections on file
- 19
- Last inspection
- 2026-03-05
*CMS
*CMS
*CMS
*CMS
Citations
52 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0637Generalpotential for harm
Assess the resident when there is a significant change in condition
- 0605Generalpotential for harm
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0700Generalpotential for harm
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.
- 0688Generalpotential for harm
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.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0603Seriousactual harm
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- 0557Generalpotential for harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0732Generalpotential for harm
Post nurse staffing information every day.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0803Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0678Seriousimmediate jeopardy
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0740Generalpotential for harm
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0585Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0803Generalpotential for harm
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.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0607Generalno actual harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0578Generalpotential for harm
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.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0758Generalpotential for harm
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.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection8 deficiencies
- View inspection reportInspectionFire Safety10 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection2 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection2 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection10 deficiencies
- View inspection reportInspectionFire Safety4 deficiencies
- View inspection reportInspection1 deficiency
Showing the 10 most recent inspections. 9 earlier inspections are also on record.
Ownership
Sanford Health
4nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Neilson Place?
- Neilson Place is a Medicare- and Medicaid-certified nursing home in Bemidji, MN, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 245039.
- What is the CMS rating for Neilson Place?
- Neilson Place has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Neilson Place have?
- Neilson Place is certified for 78 beds. It serves an average of 71.8 residents per day.
- How many citations does Neilson Place have?
- Neilson Place has 52 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Neilson Place last inspected?
- Neilson Place was last inspected on March 5, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/245039-neilson-place