Neilson Place

BEMIDJI, MN · 78 beds · Non profit - Corporation

0 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • This facility has a substantiated finding of abuse
  • 1-star health inspection rating (lowest possible)
  • 1 citation(s) at the highest severity level — immediate risk to residents
  • 5 citation(s) where residents suffered actual harm

Green Flags

  • 4-star staffing rating

Quick Facts

★☆☆☆☆
CMS Overall
★☆☆☆☆
Health Inspection
16
2.0x state avg
Deficiencies
$36,342
Fines (3-yr)
★★★★☆
Staffing

Violation Timeline

December 8, 2025

1 deficiency
F0689 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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

July 1, 2025

2 deficiencyies
F0557 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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

F0603 Actual Harm Scope/Severity: G

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

April 3, 2025

1 deficiency
F0880 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

February 24, 2025

2 deficiencyies
F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

December 19, 2024

1 deficiency
F0689 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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

December 4, 2024

10 deficiencyies
F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0692 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0732 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

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Post nurse staffing information every day.

F0756 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0759 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure medication error rates are not 5 percent or greater.

F0803 Potential Harm Scope/Severity: D

Nutrition and Dietary Deficiencies

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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.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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

F0880 Potential Harm Scope/Severity: F

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0883 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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

September 26, 2024

1 deficiency
F0678 Immediate Jeopardy Scope/Severity: J

Quality of Life and Care Deficiencies

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

July 1, 2024

2 deficiencyies
F0740 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0760 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

See full violation history →

Staffing

1.16
RN hrs/res/day
0.73
LPN hrs/res/day
2.54
CNA hrs/res/day
3.71
Weekend hrs/res/day
60%
Total nurse turnover
41%
RN turnover

A nurse checks on each resident roughly every 5.4 hours on average.

Fines & Penalties

  • Fine Sep 26, 2024
    $22,205
  • Fine Feb 28, 2024
    $14,137
Total $36,342

Ownership

Non profit - Corporation Chain: SANFORD HEALTH GOOD SAMARITAN (PROSPERA)
  • SANFORD NORTH

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 05/01/2014

    100% Organization
  • SANFORD

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 05/01/2014

    100% Organization
  • CAIN, JAMES

    CORPORATE DIRECTOR

    Since since 11/19/2015

    Individual
  • ENGBRECHT, WESLEY

    CORPORATE DIRECTOR

    Since since 01/01/2021

    Individual
  • GASSEN, WILLIAM

    CORPORATE DIRECTOR

    Since since 11/24/2020

    Individual
  • GULSVIG, NEIL

    CORPORATE DIRECTOR

    Since since 03/28/2019

    Individual
  • JACOBS, DONALD

    CORPORATE DIRECTOR

    Since since 01/01/2014

    Individual
  • LUNDEEN, MARK

    CORPORATE DIRECTOR

    Since since 01/01/2014

    Individual
  • MOLBERT, LAURIS

    CORPORATE DIRECTOR

    Since since 01/01/2021

    Individual
  • NORTH, ANDREW

    CORPORATE DIRECTOR

    Since since 01/01/2017

    Individual
  • TEIKEN, BRENT

    CORPORATE DIRECTOR

    Since since 05/01/2014

    Individual
  • VENTLING-HERRMANN, MARNIE

    CORPORATE DIRECTOR

    Since since 01/01/2022

    Individual
  • GASSEN, WILLIAM

    CORPORATE OFFICER

    Since since 11/24/2020

    Individual
  • MARLETTE, WILLIAM

    CORPORATE OFFICER

    Since since 06/16/2023

    Individual
  • MORRISON, TONY

    CORPORATE OFFICER

    Since since 02/01/1991

    Individual
  • DULSKI, KARIN

    W-2 MANAGING EMPLOYEE

    Since since 11/19/2012

    Individual
  • GASSEN, WILLIAM

    W-2 MANAGING EMPLOYEE

    Since since 11/24/2020

    Individual
  • MARLETTE, WILLIAM

    W-2 MANAGING EMPLOYEE

    Since since 06/16/2023

    Individual
  • MORRISON, TONY

    W-2 MANAGING EMPLOYEE

    Since since 02/01/1991

    Individual
  • MUNSON, JOLYN

    W-2 MANAGING EMPLOYEE

    Since since 02/25/2013

    Individual
  • SWENSON, STEPHANIE

    W-2 MANAGING EMPLOYEE

    Since since 11/01/2019

    Individual

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