Neilson Place
1000 Anne Street Northwest · Bemidji, MN · 56601 · 2187510220
78 certified beds Non profit - Corporation Chain: Sanford Health
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $41,118 in fines in the last 24 months.
- 5 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.98 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.12 | 0.55–0.75 |
| Weekend hours / resident-day | 3.32 | ≈ weekday level |
| Nursing turnover / year | 54% | median 45% |
| Fines (3-yr window) | 3 · $55,255 |
Inspection citations (47 in the current record)
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Potential for harm · D March 5, 2026
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected April 17, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 5, 2026
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 17, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 5, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 17, 2026 · Quality of Life and Care
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Potential for harm · D March 5, 2026
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.
Corrected April 17, 2026 · Quality of Life and Care
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Potential for harm · D March 5, 2026
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.
Corrected April 17, 2026 · Quality of Life and Care
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Potential for harm · E March 5, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 17, 2026 · Nutrition and Dietary
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Potential for harm · E March 5, 2026
Provide and implement an infection prevention and control program.
Corrected April 17, 2026 · Infection Control
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Potential for harm · D March 5, 2026 · found via complaint
Assess the resident when there is a significant change in condition
Corrected April 17, 2026 · Resident Assessment and Care Planning
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Actual harm · G December 9, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 12, 2025 · Quality of Life and Care
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Actual harm · G July 2, 2025 · found via complaint
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected July 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 2, 2025 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected July 28, 2025 · Resident Rights
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Potential for harm · D April 4, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected April 25, 2025 · Infection Control
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Potential for harm · D February 25, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 28, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 25, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 28, 2025 · Quality of Life and Care
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Actual harm · G December 20, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 19, 2024 · Quality of Life and Care
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Potential for harm · D December 5, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 17, 2025 · Quality of Life and Care
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Potential for harm · D December 5, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected January 17, 2025 · Quality of Life and Care
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Potential for harm · D December 5, 2024
Post nurse staffing information every day.
Corrected January 17, 2025 · Nursing and Physician Services
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Potential for harm · D December 5, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected January 17, 2025 · Pharmacy Service
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Potential for harm · D December 5, 2024
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.
Corrected January 17, 2025 · Pharmacy Service
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Potential for harm · D December 5, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected January 17, 2025 · Pharmacy Service
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Potential for harm · D December 5, 2024
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.
Corrected January 17, 2025 · Nutrition and Dietary
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Potential for harm · F December 5, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 17, 2025 · Nutrition and Dietary
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Potential for harm · F December 5, 2024
Provide and implement an infection prevention and control program.
Corrected January 17, 2025 · Infection Control
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Potential for harm · D December 5, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected January 17, 2025 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 9, 2025 | Fine | $26,685 |
| September 27, 2024 | Fine | $14,433 |
| February 29, 2024 | Fine | $14,137 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 245039 · certified since January 1, 1979. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.