Neilson Place

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• CMS abuse icon

  CMS removed its abuse icon from this home.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Fine

  CMS changed the fine from December 9, 2025 from $26,685 to $17,345.

• Ownership

  CMS lists this home under a new chain.

• Fine

  CMS changed the fine from September 27, 2024 from $22,205 to $14,433.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on April 17, 2026.

  CMS has cited this home for F0812 2 times since 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on April 17, 2026.

  CMS has cited this home for F0880 4 times since 2023.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on April 17, 2026.

• Citation F0637. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident when there is a significant change in condition

  CMS lists it as corrected on April 17, 2026.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on April 17, 2026.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on April 17, 2026.

  CMS has cited this home for F0677 2 times since 2024.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 17, 2026.

• Citation F0700. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 17, 2026.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation K0211. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on April 17, 2026.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on April 17, 2026.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on April 22, 2026.

  CMS has cited this home for K0353 2 times since 2024.

• Citation K0372. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on April 17, 2026.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on April 17, 2026.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on April 17, 2026.

  CMS has cited this home for K0761 2 times since 2024.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on April 17, 2026.

  CMS has cited this home for K0321 2 times since 2024.

• Citation K0346. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on April 17, 2026.

• Citation K0354. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on April 17, 2026.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on April 17, 2026.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

68 of 337 Minnesota homes (20%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 12, 2025.

  CMS has cited this home for F0689 4 times since 2023.

See this home on CMS Care Compare

CMS fine of $17,345 on December 9, 2025.

See this home on CMS Care Compare

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

68 of 337 Minnesota homes (20%) got a citation at the actual harm level in 2025.

• Citation F0603. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

  CMS lists it as corrected on July 28, 2025.

• Citation F0557. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on July 28, 2025.

See this home on CMS Care Compare

• Health citation

  CMS removed citation F0758 from the health inspection on December 5, 2024.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on April 25, 2025.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 28, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on February 28, 2025.

  CMS has cited this home for F0684 2 times since 2023.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

62 of 337 Minnesota homes (18%) got a citation at the actual harm level in 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 19, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Fine

  CMS changed the fine from February 29, 2024 from $13,884 to $14,137.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on January 17, 2025.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 17, 2025.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on January 17, 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on January 17, 2025.

• Citation F0732. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on January 17, 2025.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on January 17, 2025.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 17, 2025.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on January 17, 2025.

• Citation F0803. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 17, 2025.

  CMS has cited this home for F0803 2 times since 2023.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on January 17, 2025.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation K0321. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on December 31, 2024.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on March 4, 2025.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 8, 2025.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on January 10, 2025.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

54 of 337 Minnesota homes (16%) got a citation at the immediate jeopardy level in 2024.

• Citation F0678. Severity J: immediate jeopardy, isolated.

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

  CMS lists it as corrected on September 20, 2024.

See this home on CMS Care Compare

CMS fine of $14,433 on September 27, 2024.

See this home on CMS Care Compare

• Fine

  CMS changed the fine from February 29, 2024 from $21,360 to $13,884.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0740. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on August 2, 2024.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on August 2, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

62 of 337 Minnesota homes (18%) got a citation at the actual harm level in 2024.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on March 22, 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 22, 2024.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 22, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on March 22, 2024.

  CMS has cited this home for F0609 3 times since 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on March 22, 2024.

  CMS has cited this home for F0610 3 times since 2023.

See this home on CMS Care Compare

CMS fine of $14,137 on February 29, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Fine

  CMS changed the fine from June 17, 2022 from $15,000 to $9,750.

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on December 6, 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on December 6, 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on December 6, 2023.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 29, 2023.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on November 29, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 29, 2023.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 29, 2023.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on November 29, 2023.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on November 29, 2023.

• Citation F0803. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 29, 2023.

• Citation F0607. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on November 29, 2023.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on November 29, 2023.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on November 29, 2023.

• Citation K0521. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on November 29, 2023.

• Citation K0914. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on November 29, 2023.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0609. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on November 29, 2023.

• Citation F0610. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on November 29, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 29, 2023.

See this home on CMS Care Compare