Neilson Place
State inspectors recorded 1 immediate-jeopardy citation(s) here in the last three years — CMS's most serious level.
CMS has flagged this facility with its abuse icon, which marks facilities cited for abuse in recent inspections.
Serious inspection findings
2025-12-09 — ACTUAL HARM (tag F0689, severity G)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2025-07-02 — ACTUAL HARM (tag F0603, severity G)
Freedom from Abuse, Neglect, and Exploitation Deficiencies · correction not recorded in CMS data
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
2024-12-20 — ACTUAL HARM (tag F0689, severity G)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-09-27 — IMMEDIATE JEOPARDY (tag F0678, severity J)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
2024-02-29 — ACTUAL HARM (tag F0689, severity G)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-02-29 — ACTUAL HARM (tag F0686, severity G)
Quality of Life and Care Deficiencies · correction not recorded in CMS data
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Staffing, from payroll records
Nursing hours / resident / day
2.88
state median 3.48
Weekend staffing gap
−1%
fewer nursing hours on weekends · state median −4%
RN hours / resident / day
0.50
registered nurses only
Contract (agency) staff
4%
share of all nursing hours
Nursing staff turnover
55%
per year, per CMS
Keep an eye on this facility
Penalties and enforcement
3 enforcement action(s), totaling $45,915 in fines.
| Date | Type | Amount |
|---|---|---|
| 2025-12-09 | Fine | $17,345 |
| 2024-09-27 | Fine | $14,433 |
| 2024-02-29 | Fine | $14,137 |
Ownership
Ownership type: Non profit - Corporation. Part of the SANFORD HEALTH chain.
Other facilities under the same ownership, with their CMS overall ratings:
- Sylvan Court (CANBY, MN) —
- SANFORD HILLSBORO CARE CENTER (HILLSBORO, ND) —
- HILLSIDE MANOR (BEAVER DAM, WI) —
Full citation history
| Survey date | Tag | Category | Severity | Corrected |
|---|---|---|---|---|
| 2026-03-05 | F0605 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | D | not recorded |
| 2026-03-05 | F0637 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2026-03-05 | F0658 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2026-03-05 | F0677 | Quality of Life and Care Deficiencies | D | not recorded |
| 2026-03-05 | F0688 | Quality of Life and Care Deficiencies | D | not recorded |
| 2026-03-05 | F0700 | Quality of Life and Care Deficiencies | D | not recorded |
| 2026-03-05 | F0812 | Nutrition and Dietary Deficiencies | E | not recorded |
| 2026-03-05 | F0880 | Infection Control Deficiencies | E | not recorded |
| 2025-12-09 | F0689 | Quality of Life and Care Deficiencies | G | not recorded |
| 2025-07-02 | F0557 | Resident Rights Deficiencies | D | not recorded |
| 2025-07-02 | F0603 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | G | not recorded |
| 2025-04-04 | F0880 | Infection Control Deficiencies | D | not recorded |
| 2025-02-25 | F0656 | Resident Assessment and Care Planning Deficiencies | D | not recorded |
| 2025-02-25 | F0684 | Quality of Life and Care Deficiencies | D | not recorded |
| 2024-12-20 | F0689 | Quality of Life and Care Deficiencies | G | not recorded |
| 2024-12-05 | F0677 | Quality of Life and Care Deficiencies | D | not recorded |
| 2024-12-05 | F0692 | Quality of Life and Care Deficiencies | D | not recorded |
| 2024-12-05 | F0732 | Nursing and Physician Services Deficiencies | D | not recorded |
| 2024-12-05 | F0756 | Pharmacy Service Deficiencies | D | not recorded |
| 2024-12-05 | F0758 | Pharmacy Service Deficiencies | D | not recorded |
| 2024-12-05 | F0759 | Pharmacy Service Deficiencies | D | not recorded |
| 2024-12-05 | F0803 | Nutrition and Dietary Deficiencies | D | not recorded |
| 2024-12-05 | F0812 | Nutrition and Dietary Deficiencies | F | not recorded |
| 2024-12-05 | F0880 | Infection Control Deficiencies | F | not recorded |
| 2024-12-05 | F0883 | Infection Control Deficiencies | D | not recorded |
| 2024-09-27 | F0678 | Quality of Life and Care Deficiencies | J | not recorded |
| 2024-07-02 | F0740 | Quality of Life and Care Deficiencies | D | not recorded |
| 2024-07-02 | F0760 | Pharmacy Service Deficiencies | D | not recorded |
| 2024-02-29 | F0585 | Resident Rights Deficiencies | D | not recorded |
| 2024-02-29 | F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | D | not recorded |
| 2024-02-29 | F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | D | not recorded |
| 2024-02-29 | F0686 | Quality of Life and Care Deficiencies | G | not recorded |
| 2024-02-29 | F0689 | Quality of Life and Care Deficiencies | G | not recorded |
| 2023-11-09 | F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | D | not recorded |
| 2023-11-09 | F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | D | not recorded |
| 2023-11-09 | F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | D | not recorded |
| 2023-10-25 | F0550 | Resident Rights Deficiencies | D | not recorded |
| 2023-10-25 | F0578 | Resident Rights Deficiencies | D | not recorded |
| 2023-10-25 | F0607 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | C | not recorded |
| 2023-10-25 | F0679 | Quality of Life and Care Deficiencies | D | not recorded |
| 2023-10-25 | F0684 | Quality of Life and Care Deficiencies | D | not recorded |
| 2023-10-25 | F0803 | Nutrition and Dietary Deficiencies | D | not recorded |
| 2023-10-25 | F0804 | Nutrition and Dietary Deficiencies | E | not recorded |
| 2023-10-25 | F0880 | Infection Control Deficiencies | F | not recorded |
| 2023-10-19 | F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | E | not recorded |
| 2023-10-19 | F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | E | not recorded |
| 2023-10-19 | F0689 | Quality of Life and Care Deficiencies | D | not recorded |