Neilson Place
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 11 Google reviews
Watch Neilson Place
Get an email when new inspections, ratings, or penalties are published for this facility.
We’ll only email you about this — no spam, unsubscribe anytime.
Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (1/5 stars)
- Above-median deficiencies (14 vs median 6.5)
- High staff turnover (60%)
Bottom 25% in MN · Meets national RN staffing standard · Worst in SANFORD HEALTH GOOD SAMARITAN (PROSPERA) chain · $36,342 in fines · Abuse citation
What this means for your family
While some residents have had successful rehab experiences, the recent pattern of serious safety and neglect allegations is deeply concerning. If you consider this facility, you must conduct an in-person tour, observe staff response times, and ask specifically how they handle medication management and patient safety protocols.
Google Reviews
Google Reviews
11 reviews on Google“Neilson Place receives highly polarized feedback, with recent reviews highlighting severe concerns regarding patient neglect, medication management, and staff conduct. While some families report positive experiences with physical therapy and nursing care, multiple accounts describe traumatic incidents involving physical injury, unresponsiveness to call lights, and poor communication with medical professionals.”
Quality Themes
Tap a score for detailsStrengths
- Effective physical therapy programs
- Some dedicated and kind individual nursing staff
- Generous meal portions
Concerns
- Neglect and slow response to call lights (mentioned by 3 reviewers)
- Poor medication management and administration (mentioned by 2 reviewers)
- Staff rudeness or lack of empathy (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 11 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1Given the recent focus on improving communication, what is the best way for family members to receive regular, proactive updates regarding their loved one's daily well-being?
- 2I understand that medication management is a critical priority; could you walk me through the specific safety protocols and double-check systems you have in place to ensure accuracy?
- 3When a resident needs assistance, what is your internal process for monitoring and responding to call lights to ensure timely support?
- 4I’ve heard positive things about your physical therapy programs; how do you integrate those sessions into a resident’s daily routine to keep them active and engaged?
- 5How do you foster a culture of empathy and personalized care among your staff to ensure every resident feels truly heard and respected?
- 6In the event of a medical concern or emergency, what is your process for notifying family members and coordinating care with their primary physicians?
Personalized based on this facility's data
Key Review Excerpts
“My dad has been treated with total disrespect he's a decorated war hero who deserves respect this place denies him in facility treatment and visitors he moved in walking and moving around now he has broken several bones because of the neglect of the staff that are supposed to assist him”
“I had to complain to Sanford and social workers to get him out of there. On the short drive in the ambulance back to Sanford for hospice, he became unresponsive because they overdosed him on pain medicat”
“While I was there, the doctor I had took away two of my vital meds so I was tired and sleeping all the time. I also had shoulder injuries while doing therapy. I get home go to my Doctor and learn that I have two torn rotator cuff’s.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
7
measures
10
measures
Residents whose walking got worse
Residents on anti-anxiety or sleep medication
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents with pressure sores (bedsores)
Residents whose bladder or bowel control got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed reports leading to 22 complaint-triggered deficiencies at Neilson Place, revealing concerning patterns in accident prevention and safety supervision that have occurred repeatedly across multiple surveys. Issues with protecting residents from abuse and neglect, along with medication management problems, also recur in the records. While the facility has corrected most violations, the persistent nature of safety and supervision problems, particularly those serious enough to prompt family complaints, warrants careful consideration during any visit.
Mar 5, 2026Routine17
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
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.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Mar 5, 2026Complaint1
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Dec 9, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Jul 2, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Apr 4, 2025Complaint1
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Feb 25, 2025Complaint2
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Federal Penalties
Fine
Dec 9, 2025
$26,685
Fine
Sep 27, 2024
$14,433
Fine
Feb 29, 2024
$14,137
Ownership & Operations
Who Operates This Facility
Neilson Place
nonprofit
Chain Affiliation
Sanford Health
4 facilities nationwide
Chain avg rating: 2.5/5 · Rank 4 of 4 (Worst)
Ownership & Management
Owners
Sanford North
Owner · Organization
Sanford
Owner (parent company) · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
11 reviews from families & visitors
Official Website
Visit sanfordhealth.org
Medicare data downloads
Original nursing home datasets
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
Safer Alternatives Nearby
Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.
Windsong at Woodsedge
< 1 miAssisted Living · Bemidji, MN
Sanford Health Trillium
< 1 miAssisted Living · Bemidji, MN
Goldpine Home
< 1 miAssisted Living · Bemidji, MN
Autumn Hills Assisted Living
< 1 miAssisted Living · Bemidji, MN
Colleens Caring Hands INC
< 1 miAssisted Living · Bemidji, MN
Touch of Home
1.3 miAssisted Living · Bemidji, MN