F59

Neilson Place

Grade F 59/100 composite score

Non profit - CorporationAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
2/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

78

Ownership

Non profit - Corporation

Total Fines

$36,342

Last Survey

N/A

1000 ANNE STREET NORTHWEST, BEMIDJI, MN 56601
2187510220

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.16h
LPN
0.73h
CNA
2.54h
Total
4.43h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

SANFORD NORTH

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2014

100%

SANFORD

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince May 2014

100%

CAIN, JAMES

IndividualCORPORATE DIRECTORSince Nov 2015

ENGBRECHT, WESLEY

IndividualCORPORATE DIRECTORSince Jan 2021

GASSEN, WILLIAM

IndividualCORPORATE DIRECTORSince Nov 2020

GULSVIG, NEIL

IndividualCORPORATE DIRECTORSince Mar 2019

JACOBS, DONALD

IndividualCORPORATE DIRECTORSince Jan 2014

LUNDEEN, MARK

IndividualCORPORATE DIRECTORSince Jan 2014

MOLBERT, LAURIS

IndividualCORPORATE DIRECTORSince Jan 2021

NORTH, ANDREW

IndividualCORPORATE DIRECTORSince Jan 2017

TEIKEN, BRENT

IndividualCORPORATE DIRECTORSince May 2014

VENTLING-HERRMANN, MARNIE

IndividualCORPORATE DIRECTORSince Jan 2022

GASSEN, WILLIAM

IndividualCORPORATE OFFICERSince Nov 2020

MARLETTE, WILLIAM

IndividualCORPORATE OFFICERSince Jun 2023

MORRISON, TONY

IndividualCORPORATE OFFICERSince Feb 1991

DULSKI, KARIN

IndividualW-2 MANAGING EMPLOYEESince Nov 2012

GASSEN, WILLIAM

IndividualW-2 MANAGING EMPLOYEESince Nov 2020

MARLETTE, WILLIAM

IndividualW-2 MANAGING EMPLOYEESince Jun 2023

MORRISON, TONY

IndividualW-2 MANAGING EMPLOYEESince Feb 1991

MUNSON, JOLYN

IndividualW-2 MANAGING EMPLOYEESince Feb 2013

SWENSON, STEPHANIE

IndividualW-2 MANAGING EMPLOYEESince Nov 2019

Penalties & Fines (2)

$36,342total fines
DateTypeDescriptionAmount
Sep 27, 2024Fine$22,205
Feb 29, 2024Fine$14,137

Health Inspection Deficiencies (43)

July 2, 2025Health2 deficiencies1 severe
0557DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Jul 28, 2025
0603GActual harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 28, 2025
April 4, 2025Health1 deficiency
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 25, 2025
February 25, 2025Health2 deficiencies
0656DMinimal harm, Isolated

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

Corrected Feb 28, 2025
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Feb 28, 2025
December 20, 2024Health1 deficiency1 severe
0689GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Dec 19, 2024
December 5, 2024Health10 deficiencies
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 17, 2025
0692DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 17, 2025
0732DMinimal harm, Isolated

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Jan 17, 2025
0756DMinimal harm, Isolated

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

Corrected Jan 17, 2025
0758DMinimal harm, Isolated

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

Corrected Jan 17, 2025
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Jan 17, 2025
0803DMinimal harm, Isolated

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

Corrected Jan 17, 2025
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Jan 17, 2025
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jan 17, 2025
0883DMinimal harm, Isolated

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

Infection Control Deficiencies

Corrected Jan 17, 2025
September 27, 2024Health1 deficiency1 severe
0678JImmediate jeopardy, Isolated

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

Corrected Sep 20, 2024
July 2, 2024Health2 deficiencies
0740DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Aug 2, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Aug 2, 2024
February 29, 2024Health5 deficiencies2 severe
0585DMinimal harm, Isolated

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

Corrected Mar 22, 2024
0609DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 22, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 22, 2024
0686GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 22, 2024
0689GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 22, 2024
November 9, 2023Health3 deficiencies
0600DMinimal harm, Isolated

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

Corrected Dec 6, 2023
0609DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 6, 2023
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 6, 2023
October 25, 2023Health8 deficiencies
0550DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Nov 29, 2023
0578DMinimal harm, Isolated

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

Corrected Nov 29, 2023
0607CNo harm, Widespread

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 29, 2023
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Nov 29, 2023
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Nov 29, 2023
0803DMinimal harm, Isolated

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

Corrected Nov 29, 2023
0804EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Nov 29, 2023
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 29, 2023
October 19, 2023Health3 deficiencies
0609EMinimal harm, Pattern

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 29, 2023
0610EMinimal harm, Pattern

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 29, 2023
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Nov 29, 2023
March 17, 2023Health1 deficiency
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 14, 2023
September 29, 2022Health4 deficiencies
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Nov 10, 2022
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Nov 10, 2022
0758DMinimal harm, Isolated

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

Corrected Nov 10, 2022
0881DMinimal harm, Isolated

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Nov 10, 2022

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Frequently Asked Questions

What is the CareGrader rating for Neilson Place?

Neilson Place in BEMIDJI, Minnesota has a CareGrader grade of F (Poor), with a composite score of 59.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Neilson Place?

Neilson Place has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Neilson Place have?

Neilson Place has 43 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has Neilson Place been fined?

Yes. Neilson Place has $36,342 in total fines from CMS enforcement actions across 2 penalties.

How many beds does Neilson Place have?

Neilson Place has 78 certified beds with approximately 72 current residents (92% occupancy). The facility is located at 1000 ANNE STREET NORTHWEST, BEMIDJI, Minnesota 56601. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.