Your report for Neilson Place
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MinnesotaLowest tier among peers337 rated homes · average 3.2★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs MN avg
- StaffingCan add or remove a star4★−0.1 vs MN avg
- Quality measuresCan add or remove a star2★−1.2 vs MN avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMN avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 22% of peersMN avg4.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 7% of peersMN avg3.2★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.02hrsAbove only 43% of peersMN avg4.23Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only1.05hrsAbove 59% of peersMN avg1.06Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better60%Above only 10% of peersMN avg42%RN turnover41%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$36,342Above only 15% of peersMN avg$19,953Fines · denials2 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthSep 2022 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 9, 2025Cycle 1worst G · actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrection pending
Jul 2, 2025Cycle 1worst G · actual harm
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Jul 28, 2025
- F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jul 28, 2025
Apr 4, 2025Cycle 1worst D · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 25, 2025
Feb 25, 2025Cycle 1worst D · no actual harm
- F656Develop 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 PlanningD · isolatedCorrected Feb 28, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 28, 2025
Dec 20, 2024Cycle 2worst G · actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Dec 19, 2024
Dec 5, 2024Cycle 1worst F · no actual harm
- F803Ensure 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 DietaryD · isolatedCorrected Jan 17, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 17, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jan 17, 2025
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Jan 17, 2025
- F732Post nurse staffing information every day.Nursing and Physician ServicesD · isolatedCorrected Jan 17, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jan 17, 2025
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jan 17, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Jan 17, 2025
- F758Implement 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 ServiceD · isolatedCorrected Jan 17, 2025
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jan 17, 2025
Sep 27, 2024Cycle 2worst J · immediate jeopardy$22,205
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareJ · isolatedCorrected Sep 20, 2024
Jul 2, 2024Cycle 2worst D · no actual harm
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Aug 2, 2024
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Aug 2, 2024
Feb 29, 2024Cycle 2worst G · actual harm$14,137
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 22, 2024
- F585Honor 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 RightsD · isolatedCorrected Mar 22, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 22, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 22, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Mar 22, 2024
Nov 9, 2023Cycle 3worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 6, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 6, 2023
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 6, 2023
Oct 25, 2023Cycle 2worst F · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationC · widespreadCorrected Nov 29, 2023
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Nov 29, 2023
- F803Ensure 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 DietaryD · isolatedCorrected Nov 29, 2023
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Nov 29, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Nov 29, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Nov 29, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Nov 29, 2023
- F578Honor 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 RightsD · isolatedCorrected Nov 29, 2023
Oct 19, 2023Cycle 3worst E · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Nov 29, 2023
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Nov 29, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 29, 2023
Mar 17, 2023Cycle 3worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 14, 2023
Sep 29, 2022Cycle 3worst D · no actual harm
- F758Implement 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 ServiceD · isolatedCorrected Nov 10, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Nov 10, 2022
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Nov 10, 2022
- F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Nov 10, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.02hrs
- Registered nursesRN hours only1.05hrs
- Licensed practical nursesLPN hours0.66hrs
- Nurse aidesCNA hours2.31hrs
- Weekend nursingAll staff on Saturdays and Sundays3.36hrs
- Minnesota average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better60%Above only 10% of peersMN avg 42%
- RN turnoverRegistered nurses only41%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy78 certified beds · ~73 residents a day93%Above 84% of peersMN avg 83%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $36,342In fines
- 2Fines
- 0Payment denials
- $19,953MN avg in fines
Actions on record
- Sep 27, 2024Civil money penalty$22,205
- Feb 29, 2024Civil money penalty$14,137
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Sanford Health Good Samaritan (Prospera)4 facilities in the chain2.5★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- Sanford North
- Sanford
- James Cain
- Wesley Engbrecht
- William Gassen
- Neil Gulsvig
- Donald Jacobs
- Mark Lundeen
- Lauris Molbert
- Andrew North
- +2 more
- William Gassen
- William Marlette
- Tony Morrison
- Karin Dulski
- William Gassen
- William Marlette
- Tony Morrison
- Jolyn Munson
- Stephanie Swenson
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 245039 · 1000 ANNE STREET NORTHWEST, BEMIDJI, MN, 56601.
- Percentiles compare this facility with every rated nursing home in Minnesota and Beltrami County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









