Facility profile · CCN 245039
Neilson Place
44 federal citations on record , including 1 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $36,342.
Record summary
Federal record · Q1 202644
Total citations
39
Last 3 years
6
Actual harm+
2
Federal penalties
$36,342
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
44 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Dec 9, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Jul 2, 2025 | F603 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | G | Complaint |
| Jul 2, 2025 | F557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D | Complaint |
| Apr 4, 2025 | F880 | Provide and implement an infection prevention and control program. | D | Complaint |
| Feb 25, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Feb 25, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Dec 20, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Dec 5, 2024 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Dec 5, 2024 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Dec 5, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Dec 5, 2024 | F803 | 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. | D | Standard |
| Dec 5, 2024 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Dec 5, 2024 | F758 | 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. | D | Standard |
| Dec 5, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Dec 5, 2024 | F732 | Post nurse staffing information every day. | D | Standard |
| Dec 5, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Dec 5, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Sep 27, 2024 | F678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | J | Complaint |
| Jul 2, 2024 | F760 | Ensure that residents are free from significant medication errors. | D | Complaint |
| Jul 2, 2024 | F740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D | Complaint |
| Feb 29, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Feb 29, 2024 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint |
| Feb 29, 2024 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Feb 29, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Feb 29, 2024 | F585 | 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. | D | Complaint |
| Nov 9, 2023 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Nov 9, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Nov 9, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Oct 25, 2023 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Oct 25, 2023 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Standard |
| Oct 25, 2023 | F803 | 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. | D | Standard |
| Oct 25, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Oct 25, 2023 | F679 | Provide activities to meet all resident's needs. | D | Standard |
| Oct 25, 2023 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | C | Standard |
| Oct 25, 2023 | F578 | 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. | D | Standard |
| Oct 25, 2023 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard |
| Oct 19, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Oct 19, 2023 | F610 | Respond appropriately to all alleged violations. | E | Complaint |
| Oct 19, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E | Complaint |
| Mar 17, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Sep 29, 2022 | F881 | Implement a program that monitors antibiotic use. | D | Standard |
| Sep 29, 2022 | F758 | 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. | D | Standard |
| Sep 29, 2022 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard |
| Sep 29, 2022 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
Federal enforcement history
Federal regulators have imposed 2 enforcement actions against this facility, including 2 civil money penalties totaling $36,342 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Sep 27, 2024 | Fine | $22,205 | — |
| Feb 29, 2024 | Fine | $14,137 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
Concerned about care at Neilson Place?
An attorney who focuses on nursing-home abuse and neglect can review the facility's record with you — citation patterns, scope/severity levels, complaint-driven findings — and tell you whether the law recognizes what happened.
- Consultation is free and confidential
- You pay nothing unless there is a recovery
- Your note is shared only with vetted plaintiff attorneys