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LIFE BYVardellNursing Home
Report

TheVardellReport

Neilson Place

Skilled nursing facility and nursing facility

1000 Anne Street Northwest
Bemidji, MN 56601

Report Date
Nov 1, 2026
Data Through
Oct 1, 2026
Report ID
VR-MN-245039-2611
← Neilson Place, free profile

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The Vardell Report.Neilson Place

The deeper story, beautifully organized. Available records, historical context, and questions worth asking.

Provider Category
Nursing home
Location
Bemidji, MN
Record Period
2023–2026
Source Documents
15
Read the report

This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.

01

The Essentials

Summary

Across 13 inspections from October 2023 to March 2026, state surveyors documented 47 findings at Neilson Place; 47 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections
13
2023–2026, standard and complaint
Findings
47
Deficiencies cited by state inspectors
Corrected
47
Of 47 findings, with a recorded correction date
Penalties
3
3 fines; payment not published

Findings by Year

  • Findings
  • Of which, actual harm (level G or above)
2023: 14 findings across 3 inspections1420233 inspections2024: 19 findings across 5 inspections; of which, actual harm (level G or above): 41920245 inspections2025: 6 findings across 4 inspections; of which, actual harm (level G or above): 2620254 inspections2026: 8 findings across 1 inspection82026*1 inspection2023: 14 findings across 3 inspections1420233 insp.2024: 19 findings across 5 inspections; of which, actual harm (level G or above): 41920245 insp.2025: 6 findings across 4 inspections; of which, actual harm (level G or above): 2620254 insp.2026: 8 findings across 1 inspection82026*1 insp.

* Partial year, through October 1, 2026.

Findings by year
YearInspectionsFindingsOf which, actual harm (level G or above)
20233140
20245194
2025462
2026180

What the Record Shows

  • 47 of 47 findings have a recorded correction date.
  • CMS lists 3 enforcement actions in the window: 3 fines totaling $45,915, their payment not published.
  • 11 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
  • The latest standard inspection, March 5, 2026, recorded 8 findings (most serious: Level E).

What to Ask About

Report at a Glance

Facility
Neilson Place
Address
1000 Anne Street Northwest, Bemidji, MN 56601
CMS Certification Number
245039
Provider Type
Skilled nursing facility and nursing facility
Certified Beds
78
Ownership
Non profit - Corporation
Record Window
October 19, 2023 to October 1, 2026
02

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

  1. 2026

    Standard health inspection

    8 findings

    The same visit included a complaint investigation.

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Apr 17, 2026
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 17, 2026
    • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Apr 17, 2026
    • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Apr 17, 2026
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 17, 2026
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 17, 2026
    • F688Provide 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.Level DNo actual harm, potential for moreCorrected Apr 17, 2026
    • F700Try 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.Level DNo actual harm, potential for moreCorrected Apr 17, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  2. 2025

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Nov 12, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  3. 2025

    Complaint investigation

    2 findings

    • F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Level GActual harmCorrected Jul 28, 2025
    • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Jul 28, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  4. 2025

    Complaint investigation

    1 finding

    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 25, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  5. 2025

    Complaint investigation

    2 findings

    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 28, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 28, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  6. 2024

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Dec 19, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  7. 2024

    Standard health inspection

    10 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 17, 2025
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jan 17, 2025
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 17, 2025
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jan 17, 2025
    • F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected 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.Level DNo actual harm, potential for moreCorrected 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.Level DNo actual harm, potential for moreCorrected Jan 17, 2025
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 17, 2025
    • 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.Level DNo actual harm, potential for moreCorrected Jan 17, 2025
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jan 17, 2025

    Enforcement Action

    Civil money penalty, $17,345 imposed December 9, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 5, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  8. 2024

    Complaint investigation

    1 finding

    • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level JImmediate jeopardyCorrected Sep 20, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  9. 2024

    Complaint investigation

    2 findings

    • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 2, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  10. 2024

    Complaint investigation

    5 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Mar 22, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected 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.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 22, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  11. 2023

    Complaint investigation

    3 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 6, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 6, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  12. 2023

    Standard health inspection

    8 findings

    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 29, 2023
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Nov 29, 2023
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected 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.Level DNo actual harm, potential for moreCorrected Nov 29, 2023
    • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Nov 29, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected 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.Level DNo actual harm, potential for moreCorrected Nov 29, 2023
    • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level CPotential for minimal harmCorrected Nov 29, 2023

    Enforcement Action

    Civil money penalty, $14,137 imposed February 29, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 25, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $14,433 imposed September 27, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 25, 2023, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  13. 2023

    Complaint investigation

    3 findings

    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Nov 29, 2023
    • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Nov 29, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 29, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

03

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

  1. 1

    Accident Hazards and Supervision, Cited in Four Inspections

    Inspectors cited F689 in October 2023, February 2024, December 2024 and December 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F689 across all 13 inspections, oldest to newest
  2. 2

    Infection Control, Cited in Four Inspections

    Inspectors cited F880 in October 2023, December 2024, April 2025 and March 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F880 across all 13 inspections, oldest to newest
  3. 3

    Reporting Suspected Abuse, Cited in Three Inspections

    Inspectors cited F609 in October 2023, November 2023 and February 2024. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F609 across all 13 inspections, oldest to newest
  4. 4

    Investigating Alleged Violations, Cited in Three Inspections

    Inspectors cited F610 in October 2023, November 2023 and February 2024. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F610 across all 13 inspections, oldest to newest
  5. 5

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in December 2024 and March 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F677 across all 13 inspections, oldest to newest
  6. 6

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in October 2023 and February 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F684 across all 13 inspections, oldest to newest
  7. 7

    Citation F803, Cited in Two Inspections

    Inspectors cited F803 in October 2023 and December 2024. The agency describes it this way: 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F803 across all 13 inspections, oldest to newest
  8. 8

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in December 2024 and March 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232324242424242525252526F812 across all 13 inspections, oldest to newest
04

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

  1. 01

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in four inspections, most seriously at level G.

  2. 02

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in four inspections, most seriously at level F.

  3. 03

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in three inspections, most seriously at level E.

  4. 04

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in three inspections, most seriously at level E.

  5. 05

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in two inspections, most seriously at level D.

  6. 06

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level D.

  7. 07

    What changed after F803 was cited, and how do you check it now?

    Citation F803: cited in two inspections, most seriously at level D.

  8. 08

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in two inspections, most seriously at level F.

  9. 09

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

  10. 10

    What led to the 2025 fine, and has it been paid?

    A $17,345 civil money penalty was imposed December 9, 2025. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

05

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Minnesota state survey agency.

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Oct 19, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Oct 25, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Nov 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Feb 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Jul 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Sep 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Dec 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Dec 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Feb 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Apr 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Jul 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Dec 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Minnesota state survey agency

    Inspection Mar 5, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Penalties, Provider Data Catalog

    Centers for Medicare & Medicaid Services

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗
  • Provider Information, Provider Data Catalog

    Centers for Medicare & Medicaid Services · 245039

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗

Coverage

Record windowOctober 19, 2023 – October 1, 2026

  • CMS publishes about three inspection cycles; inspections before October 2023 are not in this release.
  • CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite
Allegations screened out by the state before an onsite visit are not published.
Complaint allegations
CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents
Self-reported incidents appear only if they led to an inspection.
Follow-up visits
CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections
Published by CMS separately and not included in this record yet.
Staffing levels and ownership history
Published by CMS separately and not included in this record.
Whether fines were paid
CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.