NursingHomeGrade

NEILSON PLACE

1000 ANNE STREET NORTHWEST, BEMIDJI, MN 56601

Operator

SANFORD NORTH · 2 facilities

Provider number (CCN)
245039
Certification
Medicare and Medicaid
Ownership
Non profit - Corporation
Certified beds
78
Phone
(218) 751-0220
CMS data as of
August 1, 2026
C
●
stable

Staffing 0% · Deficiencies -18% over tracking period

What the records show

CMS rates NEILSON PLACE 1 out of 5 stars overall, with 1 of 5 for health inspections, 4 of 5 for staffing, 2 of 5 for quality measures. Federal inspectors cited 47 health deficiencies across the last three survey cycles, most recently surveyed in 2026, 6 at actual-harm level or higher. CMS enforcement records list 3 fines totalling $45,915.

Facility Assessment Inspectors recorded 6 citations at the actual-harm level or worse in the last three survey cycles. This facility is operated by SANFORD NORTH, which scores 11 points above the national average.

Reviews, Ratings and Official Records

This page reviews NEILSON PLACE using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.

At or above the 2024 benchmark — review the inspection and enforcement records below for the safety history behind the grade.

Ratings and Grade Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
 0.89 — At or above the repealed 0.55 hr benchmark

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 47
Outstanding 0
Actual harm or worse (G–L) 6
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
Overall: ★☆☆☆☆ (1/5)
Health inspection: ★☆☆☆☆ (1/5)
Quality: ★★☆☆☆ (2/5)
Staffing: ★★★★☆ (4/5)
NursingHomeGrade Score
 52/100

Loaded into NursingHomeGrade on September 5, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.

Staffing Compared With State and National Levels

This facility0.89 hrs
MN median0.97 hrs
National average0.69 hrs

Registered nurse turnover: 42.9% · Total nursing staff turnover: 55.4%

Staffing figures are the values CMS published in its file processed August 1, 2026, drawn from payroll-based journal reporting.

Inspection Records Covered

Source records: CMS Care Compare profile for provider 245039 ↗ · the federal files we load and when.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

1 immediate jeopardy, 5 actual harm issues found among 47 total deficiencies. 47 corrected.

Most recent inspection (March 5, 2026)

D Potential harm — isolated F0605 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

E Potential harm — pattern F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

D Potential harm — isolated F0677 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

D Potential harm — isolated F0688 Status: Corrected

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

D Potential harm — isolated F0700 Status: Corrected

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

G Actual harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Past Non-Compliance, corrected November 12, 2025

D Potential harm — isolated F0637 Status: Corrected

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

D Potential harm — isolated F0658 Status: Corrected

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2026

Inspection cycle 2 (July 2, 2025)

G Actual harm — isolated F0603 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2025

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 25, 2025

F Potential harm — widespread F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0883 Status: Corrected

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

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0732 Status: Corrected

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

F Potential harm — widespread F0812 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0803 Status: Corrected

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.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0756 Status: Corrected

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

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0758 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0684 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2025

G Actual harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Past Non-Compliance, corrected December 19, 2024

D Potential harm — isolated F0677 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

D Potential harm — isolated F0692 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025

J Immediate jeopardy — isolated F0678 Status: Corrected

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

Quality of Life and Care Deficiencies — Past Non-Compliance, corrected September 20, 2024

D Potential harm — isolated F0656 Status: Corrected

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2025

D Potential harm — isolated F0557 Status: Corrected

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2025

Inspection cycle 3 (February 29, 2024)

D Potential harm — isolated F0609 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 22, 2024

D Potential harm — isolated F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 22, 2024

D Potential harm — isolated F0600 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 6, 2023

D Potential harm — isolated F0609 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 6, 2023

D Potential harm — isolated F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 6, 2023

C No harm — widespread F0607 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

E Potential harm — pattern F0609 Status: Corrected

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

E Potential harm — pattern F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

F Potential harm — widespread F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

E Potential harm — pattern F0804 Status: Corrected

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

D Potential harm — isolated F0803 Status: Corrected

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.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

D Potential harm — isolated F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 2, 2024

D Potential harm — isolated F0740 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 2, 2024

G Actual harm — isolated F0686 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 22, 2024

G Actual harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 22, 2024

D Potential harm — isolated F0679 Status: Corrected

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

D Potential harm — isolated F0684 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

D Potential harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

D Potential harm — isolated F0585 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 22, 2024

D Potential harm — isolated F0550 Status: Corrected

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

D Potential harm — isolated F0578 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 29, 2023

Fines and Enforcement Actions

Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.

Date Action Amount or length
December 9, 2025 Fine $17,345
September 27, 2024 Fine $14,433
February 29, 2024 Fine $14,137

3 fines totalling $45,915.

Source: CMS Penalties file (dataset g6vv-u9sr).

Ownership and Contact Information

Facility name
NEILSON PLACE
Legal business name
SANFORD HEALTH OF NORTHERN MINNESOTA
Address
1000 ANNE STREET NORTHWEST, BEMIDJI, MN 56601
Phone
(218) 751-0220
Provider number (CCN)
245039
Ownership type
Non profit - Corporation
Operator
SANFORD NORTH · 2 facilities
Medicare/Medicaid certified since
January 1, 1979
Official record
CMS Care Compare profile ↗
Details verified against CMS data dated
August 1, 2026

The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.

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Sources and Methodology

The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.

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