Neilson Place
Neilson Place in BEMIDJI, MN — inspection on March 5, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the physician progress notes identified the physician had dictated R6 was often up late at night, had difficulty getting to sleep and then sleeping during the day. RN-C stated there would be other options to try before prescribing an antipsychotic medication. RN-C did not believe any other options were attempted other than just starting the Seroquel.
During interview on 3/5/26, at 4:45 p.m. the director of nursing (DON) stated a psychotropic medication would be added if there would be a danger to self or others or could be for an emotional outcome as well. R6 had been admitted to the facility in October 2025, and the Seroquel had been started on 1/6/26.
The Seroquel was at a pretty low dose.
Review of the physician note did identify the medication had been started for sleep.
The provider would have been aware nothing else had been tried previously.
Targeted behaviors and other things for sleep should have been implemented prior to starting the antipsychotic.
The facility policy Psychotropic Medications dated 12/9/25, identified residents would be free from any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms.
Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used psychotropic drugs were not given those drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record.
Before administration of non-emergency psychotropic medications, the following must be competed: a. documentation in the plan of care observations of mood, symptoms or behaviors that caused the resident distress and/or endangered the resident or others and response to interventions used. b. the behavior committee and or care plan team would ensure the care plan was updated and would reflect non-pharmacological interventions to be used and the physician and family would be notified of the change in condition.
After reviewing the mood and behavior documentation, if the behavior committee and/or care plan team determined psychotropic medications necessary, the reduction committee must be notified. If the reduction committed determined initiating the medication was warranted, the committee nurse would ensure the physician was contacted with description of the behavior, attempted interventions and committee recommendations.
Obtain an order for an appropriate medication, in an appropriate dose and corresponding diagnosis, as well as medical symptoms from the physician.
245039 03/05/2026
Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601
which a resident is judged to be unstable
245039 03/05/2026
Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601
During an interview on 3/3/26 at 11:47 a.m., NA-G stated she always left R63's footrests on and only takes the footrests off when R63 was transferred out of her wheelchair. NA-G stated she did this because staff would just take off with R63 and not put on the footrests.
During an interview on 3/3/26 at 2:01 p.m., registered nurse (RN)-C stated R63's footrests should have been removed and placed into the bag on the back of R63's wheelchair. R63 was more likely to try to climb over the footrests and potentially fall.During an observation on 3/4/26 at 9:50 a.m., NA-H assisted R63 to the dining room. R63 was sitting in her wheelchair at the dining table with the footrests on and her feet up against the table pedestal. NA-H did not remove R63's footrests and left the dining room.
There was no bag on the back of R63's wheelchair for the footrests.
During an interview on 3/4/26 at 9:51 a.m., NA-H stated she did not know R63 well but did get R63 up that morning. NA-H stated she was unaware R63 should have the footrests only for transportation. NA-H then placed R63's feet on the floor and turned the footrests away from the front of R63 but left the footrests connected to the wheelchair.
During an interview on 3/5/26 at 1:40 p.m., the director of nursing (DON) stated staff were expected to follow the resident care plans for the safety of all residents.A care plan policy was requested but not received.
245039 03/05/2026
Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601
During an observation on 3/3/26 at 9:03 a.m., nursing assistant (NA)-G assisted R63 with her morning cares. R63 was incontinent of urine. NA-G did not offer toileting nor toileted R63. R63 was wheeled to the dining room for breakfast.
At 11:26 a.m., R63 continued to sit at the dining room table. R63 had not been offered toileting.
At 11:34 a.m., registered nurse (RN)-G assisted R63 into R63's room and stated NA-G would take R63 to the bathroom before lunch and left the room.
At 11:36 a.m., NA-G brought R63 into the bathroom and transferred R63 onto the toilet using the sit-to-stand aid. R63 incontinence brief was wet with urine and R63 immediately voided when R63 sat down on the toilet.
During an interview on 3/3/26 at 11:47 a.m., NA-G stated she did not toilet R63 when NA-G assisted R63 with morning cares and should have.
During an interview on 3/3/26 at 1:52 p.m., RN-G stated residents were expected to be at least checked and changed every 2 hours or whatever was care planned. R63 was supposed to be toileted every 2-3 hours.
During an interview on 3/3/26 at 2:01 p.m., RN-C stated R63 was more of a check and change and, if R63 was alert, R63 may sit on the toilet.
Staff were expected to follow R63's care plan.
During an interview on 3/5/26 at 1:40 p.m., the director of nursing (DON) stated staff were expected to follow the care plan for toileting.
During an interview on 3/5/26 at 2:50 p.m., the administrator stated staff were expected to follow the care plan for toileting.
245039 03/05/2026
Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601
F 0677 R46:
included dementia, diabetes, and neurogenic bladder.
R46's care plan dated 2/12/26, identified R46 had a self-care deficit related to weakness, history of cerebral vascular accident.
Staff were directed to assist R46 with bathing.
The care plan lacked any guidance or direction on fingernail care including what, if any, preference for length R10 had or how often they should be checked or clipped.
On 3/4/26, at 1:58 p.m. R46 was observed seated in his wheelchair in his room with NA-F also present. R46's fingernails were long on both his hands extending a centimeter or more beyond his fingertips. R46 stated he knew his fingernails were very long and he preferred to keep his fingernails short. R46 stated he asked a staff member a few days previously if they would trim his fingernails for him.
The staff had agreed to assist him with the task but never returned. NA-F stated he thought R46 was diabetic and so a nurse would have to trim his nails. It was the facility policy the aides were not allowed to trim finger or toenails of diabetic residents. NA-F stated he would find out and if able would make sure he came back later to trim R46's nails or ask the nurse to do so.
On 3/5/26, at 5:28 p.m. R46 was again observed seated in his wheelchair in the dining room. R46 again stated his fingernails were very long. R46 stated no one had come to trim them for him.
The staff member he had asked to trim them told him she would but then said she did not have time.
During interview on 3/5/36, at 5:30 p.m. licensed practical nurse (LPN)-E stated diabetic residents nails were done by the nurses. LPN-E was not aware R46 had wanted his fingernails trimmed.
Staff should have trimmed his nails when he had requested it or as soon as reasonably possible. LPN-E would check with R46 and try to trim his nails that evening.
During interview on 3/5/26, at 5:33 p.m. the director of nursing (DON) stated staff should trim resident nails when it was requested.
An activities of daily living (ADL) policy was requested but not received.
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Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601
should have offered it at other times throughout the day.
There should be something in the chart to
Restorative- Nursing Care Implementation and Screening dated 12/8/25, identified each resident
and problems as defined in nursing assessments.
The restorative care would be outlined in the resident's nursing care plan.
Residents would be provided appropriate treatment and services to attain/maintainfunctional abilities in activities of daily living.
Any resident who was unable to carry out independent activities of daily living would receive necessary services to prevent further diminishing of independent abilities in bathing, dressing/undressing, grooming, transfer and ambulation, toileting, eating and use of speech, language or other functional communication systems.
245039 03/05/2026
Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601
During an interview on 3/4/26 at 9:51 a.m., NA-H stated she just took the drawsheet and just kind of turned R63. R63 didn't really participate, and NA-H did most of the work. R63 did understand verbal cues but just kind of laid there.
During an interview on 3/4/26 at 10:39 a.m., RN-E stated R63 was admitted to the facility for physical therapy. R63 was very weak and lethargic. R63 did not use the side rails for bed mobility. It was a boundary limitation for R63 because R63 tried to get out of bed. RN-E spoke with R63's family and they were adamant R63 had side rails for safety. RN-E stated a device to keep a resident in bed was a restraint. RN-E stated she educated R63's family and they signed the consent for siderails for boundary limitations.
That's what the facility did when a resident's family insisted on side rails.
During an interview on 3/5/26 at 1:40 p.m., the director of nursing (DON) stated R63's side rail assessment should not say boundary limitations.
Side rails were to be used only to assist with bed mobility.
Family should be educated regarding the risks of using a side rail because that would be a restraint. R63's side rails were ¾ rails, so they were unable to keep R63 in bed. R63 should be reassessed to determine if side rails were a safe intervention for R63 because side rails were supposed to help keep R63's independence.
During an interview on 3/5/26 at 2:50 p.m., the administrator stated staff were expected to comprehensively assess side rails to ensure resident safety.
A side rail policy was requested but not received.
breakfasts and as needed with individual resident requests.
The stove top and between each of the
the surface.
Lumps of dark black substances were visible in the grates of the stove between the
splash of the stove had visible black and spattered greasy substance scattered over the surface.
When interviewed on 3/5/26, at 2:40 p.m. DM-B stated there was currently no cleaning schedule set up for maintenance cleaning of the equipment such as the stove.
The facility currently used a daily cleaning schedule; however, it did not include to clean the stove top, griddle and splash guards.
The stoves in the three units did need to be cleaned and was on her list of things to get completed.
Food could be potentially contaminated when cooking on the unclean equipment.
The grates on the stove could be removed and deep cleaned, and she would see the stoves in the kitchenettes were cleaned.
DM-B stated it was important for staff to label and date the food in the freezer to know what the food was and when it could no longer be used and needed to be thrown out. DM-B removed both bags of food from the freezer on Strawberry unit and threw them into the garbage. DM-B stated there would be no way to tell how old the food was, when the suggested expiration date was or when it had been opened.
The facility policy General Sanitation-Food and Nutrition dated 6/27/25, identified cleaning and sanitizing equipment surfaces was a two-step process.
Surfaces were to be cleaned and rinsed before being sanitized.
All food contact surfaces would be washed, rinsed and sanitized:a.
After each use.b.
When working with one kind of food to another.c.
Any time there is an interruption during a task with the tools or items being used or with any that may have been contaminated.When cleaning fixed/immobile equipment such as mixers and slicers, removable parts would be washed and sanitized.
Non-removable parts were to be cleaned with detergent and hot water, rinsed, air dried and sprayed with sanitizing solution at effective concentration, If any foodcontact surfaces were contaminated during reassembly, staff were to re-sanitize.
The facility policy Food Supply Storage- Food and Nutrition dated 3/7/25, identified foods that had been opened or prepared were to be placed in an enclosed container, dated, labeled and stored properly.
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Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601
The facility failed to immediately place R16 on isolation precautions resulting in two other residents being exposed to COVID-19.
On 3/5/26 at 2:29 p.m., RN-B stated he worked the evening shift on 3/3/26 and was notified R16 had stomach discomfort and was not feeling well. RN-B couldn't remember the exact time, but stated sometime after the evening meal, LPN-A told him R16 tested positive for COVID-19 and would be placed on airborne/contact precautions. RN-B stated he had not seen R16 the rest of the evening and was uncertain if or what time LPN-B had placed R16 in precautions.
The facility Standard, Enhanced Barrier, and Transmission-Based Precautions policy dated 7/7/25, identified EBP expanded the use of personal protective equipment beyond situations in which exposure to blood and body fluids was anticipated and referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. EBP was also used for residents with indwelling medical devices (i.e., indwelling urinary catheters), even if the resident was not known to be infected or colonized with an MDRO.
High-contact resident care activities included transfers and indwelling medical device care.
The policy further identified airborne isolation/precautions was used for illnesses including COVID-19 and staff were to wear PPE including N95, gown, gloves and eye protection when providing direct care to resident's positive for COVID-19.
245039 03/05/2026
Neilson Place 1000 Anne Street Northwest Bemidji, MN 56601