Facility Watch Inspection records for every certified US nursing home

Neilson Place

1000 Anne Street Northwest
Bemidji, MN 56601
(218) 751-0220

Abuse icon
CCN
245039
Certified beds
78
Ownership
Non profit - Corporation
Chain
Sanford Health

Nurse staffing

4.34
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 1.22 hours per resident per day

Nursing staff turnover: 54% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected March 5, 2026

8 citations · from a complaint investigation · Health
D
F0605 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected April 17, 2026
D
F0637 No actual harm with potential for more than minimal harm · Isolated

Assess the resident when there is a significant change in condition

Deficient, Provider has date of correction · corrected April 17, 2026
D
F0658 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected April 17, 2026
D
F0677 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected April 17, 2026
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected April 17, 2026
D
F0700 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected April 17, 2026
E
F0812 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected April 17, 2026
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected April 17, 2026

Inspected December 9, 2025

1 citation · from a complaint investigation · Health
G
F0689 Actual harm · Isolated

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

Past Non-Compliance · corrected November 12, 2025

Inspected July 2, 2025

2 citations · from a complaint investigation · Health
D
F0557 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 28, 2025
G
F0603 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected July 28, 2025

Inspected April 4, 2025

1 citation · from a complaint investigation · Health
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected April 25, 2025

Inspected February 25, 2025

2 citations · from a complaint investigation · Health
D
F0656 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected February 28, 2025
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected February 28, 2025

Inspected December 20, 2024

1 citation · from a complaint investigation · Health
G
F0689 Actual harm · Isolated

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

Past Non-Compliance · corrected December 19, 2024

Inspected December 5, 2024

10 citations · Health
D
F0677 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 17, 2025
D
F0692 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 17, 2025
D
F0732 No actual harm with potential for more than minimal harm · Isolated

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected January 17, 2025
D
F0756 No actual harm with potential for more than minimal 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.

Deficient, Provider has date of correction · corrected January 17, 2025
D
F0758 No actual harm with potential for more than minimal 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.

Deficient, Provider has date of correction · corrected January 17, 2025
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected January 17, 2025
D
F0803 No actual harm with potential for more than minimal 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.

Deficient, Provider has date of correction · corrected January 17, 2025
D
F0883 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 17, 2025
F
F0812 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected January 17, 2025
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected January 17, 2025

Inspected September 27, 2024

1 citation · from a complaint investigation · Health
J
F0678 Immediate jeopardy to resident health or safety · 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.

Past Non-Compliance · corrected September 20, 2024

Inspected July 2, 2024

2 citations · from a complaint investigation · Health
D
F0740 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 2, 2024
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected August 2, 2024

Inspected February 29, 2024

5 citations · from a complaint investigation · Health
D
F0585 No actual harm with potential for more than minimal 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.

Deficient, Provider has date of correction · corrected March 22, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected March 22, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected March 22, 2024
G
F0686 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected March 22, 2024
G
F0689 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected March 22, 2024

Inspected November 9, 2023

3 citations · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 6, 2023
D
F0609 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 6, 2023
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected December 6, 2023

Inspected October 25, 2023

8 citations · Health
C
F0607 No actual harm with potential for minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected November 29, 2023
D
F0550 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 29, 2023
D
F0578 No actual harm with potential for more than minimal 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.

Deficient, Provider has date of correction · corrected November 29, 2023
D
F0679 No actual harm with potential for more than minimal harm · Isolated

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected November 29, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 29, 2023
D
F0803 No actual harm with potential for more than minimal 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.

Deficient, Provider has date of correction · corrected November 29, 2023
E
F0804 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected November 29, 2023
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected November 29, 2023

Inspected October 19, 2023

3 citations · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 29, 2023
E
F0609 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected November 29, 2023
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected November 29, 2023

Penalties

DateTypeAmount
December 9, 2025Fine$26,685
September 27, 2024Fine$14,433
February 29, 2024Fine$14,137