Neilson Place

Penalties

• Dec 9, 2025 — Fine ($17,345)
• Sep 27, 2024 — Fine ($14,433)
• Feb 29, 2024 — Fine ($14,137)

Inspection findings

1. Mar 5, 2026 Health · 18 findings
   • Not serious Scope/severity D

     F0605 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.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0637 Resident Assessment and Care Planning Deficiencies

     Assess the resident when there is a significant change in condition

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0658 Resident Assessment and Care Planning Deficiencies

     Ensure services provided by the nursing facility meet professional standards of quality.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0688 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.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0700 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.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

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

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 22, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Apr 17, 2026 · CMS fire safety

2. Dec 30, 2025 MDH complaint investigation · 1 finding
   • Severity not stated

     H50397487C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

3. Dec 9, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 12, 2025 · CMS health inspection

4. Jul 18, 2025 MDH complaint investigation · 2 findings
   • Severity not stated

     H50398288C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H50398451C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

5. Jul 2, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0557 Resident Rights Deficiencies

     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

     Corrected Jul 28, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0603 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

     Corrected Jul 28, 2025 · CMS health inspection

6. Apr 4, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 25, 2025 · CMS health inspection

7. Feb 25, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Feb 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Feb 28, 2025 · CMS health inspection

8. Dec 31, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H50392935C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

9. Dec 20, 2024 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 19, 2024 · CMS health inspection

10. Dec 5, 2024 Health · 14 findings
    • Not serious Scope/severity D

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0692 Quality of Life and Care Deficiencies

      Provide enough food/fluids to maintain a resident's health.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0732 Nursing and Physician Services Deficiencies

      Post nurse staffing information every day.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0756 Pharmacy Service Deficiencies

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

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      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.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0803 Nutrition and Dietary Deficiencies

      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.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity F

      F0812 Nutrition and Dietary Deficiencies

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

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity F

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0883 Infection Control Deficiencies

      Develop and implement policies and procedures for flu and pneumonia vaccinations.

      Corrected Jan 17, 2025 · CMS health inspection

    • Not serious Scope/severity F

      K0321 Smoke Deficiencies

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

      Corrected Dec 31, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Jan 8, 2025 · CMS fire safety

    • Not serious Scope/severity F

      K0761 Miscellaneous Deficiencies

      To conduct inspection, testing and maintenance of fire doors by qualified individuals.

      Corrected Mar 4, 2025 · CMS fire safety

    • Not serious Scope/severity D

      K0920 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure proper usage of power strips and extension cords.

      Corrected Jan 10, 2025 · CMS fire safety

11. Oct 4, 2024 MDH complaint investigation · 1 finding
    • Severity not stated

      H50398660C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

12. Sep 27, 2024 Health · 1 finding
    • Serious Scope/severity J Complaint

      F0678 Quality of Life and Care Deficiencies

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

      Corrected Sep 20, 2024 · CMS health inspection

13. Sep 19, 2024 MDH complaint investigation · 1 finding
    • Severity not stated

      H50398042C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

14. Jul 10, 2024 MDH complaint investigation · 1 finding
    • Severity not stated

      H50395082C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

15. Jul 2, 2024 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0740 Quality of Life and Care Deficiencies

      Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

      Corrected Aug 2, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0760 Pharmacy Service Deficiencies

      Ensure that residents are free from significant medication errors.

      Corrected Aug 2, 2024 · CMS health inspection

16. Mar 8, 2024 MDH complaint investigation · 1 finding
    • Severity not stated

      H50391140C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

17. Feb 29, 2024 Health · 5 findings
    • Not serious Scope/severity D Complaint

      F0585 Resident Rights Deficiencies

      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.

      Corrected Mar 22, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Mar 22, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Mar 22, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Mar 22, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Mar 22, 2024 · CMS health inspection

18. Dec 22, 2023 MDH complaint investigation · 1 finding
    • Severity not stated

      H50397918C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

19. Nov 22, 2023 MDH complaint investigation · 2 findings
    • Severity not stated

      H50396966C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50397072C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

20. Nov 9, 2023 Health · 3 findings
    • Not serious Scope/severity D Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

      Corrected Dec 6, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Dec 6, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Dec 6, 2023 · CMS health inspection

21. Oct 31, 2023 MDH complaint investigation · 6 findings
    • Severity not stated

      H50396477C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50396483C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50396491C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50396494C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50396566C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50396606C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

22. Oct 25, 2023 Health · 12 findings
    • Not serious Scope/severity D

      F0550 Resident Rights Deficiencies

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

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0578 Resident Rights Deficiencies

      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.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity C

      F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Develop and implement policies and procedures to prevent abuse, neglect, and theft.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0679 Quality of Life and Care Deficiencies

      Provide activities to meet all resident's needs.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0803 Nutrition and Dietary Deficiencies

      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.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0804 Nutrition and Dietary Deficiencies

      Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity F

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity F

      K0222 Egress Deficiencies

      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.

      Corrected Nov 29, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Nov 29, 2023 · CMS fire safety

    • Not serious Scope/severity C

      K0914 Gas, Vacuum, and Electrical Systems Deficiencies

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

      Corrected Nov 29, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Nov 29, 2023 · CMS fire safety

23. Oct 19, 2023 Health · 3 findings
    • Not serious Scope/severity E Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Nov 29, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Nov 29, 2023 · CMS health inspection

24. May 8, 2023 MDH complaint investigation · 3 findings
    • Severity not stated

      H50391494C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50391902C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H50391904C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

25. Jun 28, 2022 MDH complaint investigation · 1 finding
    • Severity not stated

      H50392429C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

26. Sep 8, 2021 MDH complaint investigation · 1 finding
    • Severity not stated

      H5039051C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

27. Jun 26, 2020 MDH complaint investigation · 1 finding
    • Severity not stated

      H5039038C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• CAIN, JAMES — corporate director, NOT APPLICABLE, since 11/19/2015
• DULSKI, KARIN — w-2 managing employee, NOT APPLICABLE, since 11/19/2012
• ENGBRECHT, WESLEY — corporate director, NOT APPLICABLE, since 01/01/2021
• GASSEN, WILLIAM — corporate officer, NOT APPLICABLE, since 11/24/2020
• GASSEN, WILLIAM — corporate director, NOT APPLICABLE, since 11/24/2020
• GASSEN, WILLIAM — w-2 managing employee, NOT APPLICABLE, since 11/24/2020
• GULSVIG, NEIL — corporate director, NOT APPLICABLE, since 03/28/2019
• JACOBS, DONALD — corporate director, NOT APPLICABLE, since 01/01/2014
• LUNDEEN, MARK — corporate director, NOT APPLICABLE, since 01/01/2014
• MARLETTE, WILLIAM — corporate officer, NOT APPLICABLE, since 06/16/2023
• MARLETTE, WILLIAM — w-2 managing employee, NOT APPLICABLE, since 06/16/2023
• MOLBERT, LAURIS — corporate director, NOT APPLICABLE, since 01/01/2021
• MORRISON, TONY — corporate officer, NOT APPLICABLE, since 02/01/1991
• MORRISON, TONY — w-2 managing employee, NOT APPLICABLE, since 02/01/1991
• MUNSON, JOLYN — w-2 managing employee, NOT APPLICABLE, since 02/25/2013
• NORTH, ANDREW — corporate director, NOT APPLICABLE, since 01/01/2017
• SWENSON, STEPHANIE — w-2 managing employee, NOT APPLICABLE, since 11/01/2019
• TEIKEN, BRENT — corporate director, NOT APPLICABLE, since 05/01/2014
• VENTLING-HERRMANN, MARNIE — corporate director, NOT APPLICABLE, since 01/01/2022
• SANFORD — 5% or greater indirect ownership interest, 100%, since 05/01/2014
• SANFORD NORTH — 5% or greater direct ownership interest, 100%, since 05/01/2014