Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Estates At Bloomington Llc during CMS and state inspections, most recent first.
Failure to respect resident dignity occurred when staff entered a shared room without knocking, introducing themselves, or waiting for permission. Two NAs entered the room of a resident with dementia, psychosis, total care needs, and hospice enrollment, as well as a cognitively intact resident with fibromyalgia, anxiety, depression, and chronic pain, and later re-entered without knocking. The cognitively intact resident reported that staff often entered without permission and described an incident where a staff member looked in while she was naked.
Call Light Not Kept Within Reach: A resident with impaired cognition, dementia, and hospice status was observed without a call light within reach. A NA wheeled the resident into the middle of the room and left without placing the call light nearby, and later the call light was found attached under a pillow and out of sight while the resident was in bed. The NA and DON both stated call lights should be within reach, and facility policy required communication devices to be placed within reach of each resident.
A resident with impaired cognition, hemiplegia, diabetes, and anxiety was transferred to the ER for diarrhea, but the facility did not provide or document a written transfer notice or bed-hold notice. The RN said he believed he left a message with the guardian but did not document it, and the DON verified the EMR lacked the required forms and follow-up.
Failure to develop and implement a comprehensive, person-centered care plan for a resident with polydipsia and severe cognitive impairment. The resident repeatedly sought fluids, tried to get drinks from other residents, and drank water from the bathroom sink. Staff used an 1800 mL fluid restriction, thickened liquids, redirection, a closed bathroom door, and a commode, but the care plan and TAR lacked resident-specific interventions to guide management of the ongoing fluid-seeking behavior.
Incomplete BIPAP Orders and Missing Respiratory Settings Documentation: A resident with intact cognition and use of a non-invasive ventilator had BIPAP orders for bedtime use, daily water changes, and weekly cleaning, but the orders did not include specific settings or clear direction to verify or maintain them. Staff stated BIPAP units were typically pre-set by a respiratory company and nurses checked them, but the resident’s record lacked documentation of the respiratory company setup and the specific BIPAP settings.
Failure to document non-pharmacological pain interventions before PRN medication administration. Two residents with intact cognition received repeated PRN opioid and muscle relaxant doses for pain, but the MAR/TAR, progress notes, and medical record lacked evidence that non-medication measures such as repositioning, rest, massage, or other comfort measures were offered or attempted before the medications were given. Although care plans referenced non-medicinal pain relief, staff interviews confirmed the expectation to offer and document these interventions, and the DON acknowledged the missing documentation for one resident.
Failure to maintain bedroom ceiling lights for two residents. One resident had impaired cognition, dementia, and was enrolled in hospice, while the other had intact cognition and diagnoses including fibromyalgia, anxiety, depression, and chronic pain. The second resident reported a flickering ceiling light that had not worked for a long time, caused headaches, and left the room dark unless she used the pull-string light. Staff said maintenance requests were supposed to be entered in TELS, but the DON and MT-D confirmed no request had been submitted for the issue.
The facility failed to properly clean and disinfect community-use glucometers between uses, affecting nine diabetic residents. Staff did not follow the manufacturer's instructions, using hand sanitizer instead of EPA-registered wipes and not adhering to required contact times. Additionally, residents' fingers were not washed with soap and water before testing. Interviews revealed inconsistencies in staff knowledge and implementation of proper procedures, and the facility's policy on cleaning medical equipment was not provided.
Two residents shared a room with an unfinished wall, which had been left unsanded and unpainted since October 2024. Despite the residents' complaints about the unhomelike environment, staff failed to notice or report the issue for maintenance. The maintenance director cited logistical challenges in completing the repair, and the facility's maintenance policy was not provided.
A resident with severe cognitive impairment was not provided with dentures, which were necessary for safe and independent eating. Despite having a care plan indicating the use of dentures, staff were unaware of their presence and did not offer them during morning care. The interim DON confirmed that refusals were not documented, leading to a failure in providing appropriate care.
A resident in a LTC facility did not receive routine nail care despite needing assistance with ADLs. The resident had long, yellow fingernails and a cracked toenail, and expressed dissatisfaction with the lack of assistance. Staff were responsible for trimming nails on bath days, but assessments inaccurately indicated no need for trimming. The facility's policy emphasized necessary services for grooming, which was not followed.
The facility failed to assess and address poor wheelchair posture for a resident with severe cognitive impairment and functional limitations, as well as to provide necessary interventions for another resident with limited ROM. Observations showed inadequate wheelchair positioning and lack of protective devices, with staff unaware of required interventions. The facility's policies lacked guidance on therapy referrals, leading to deficiencies in resident care.
A resident with worsening hearing loss did not receive a timely audiology consult despite a provider's order. The Health Information Manager confirmed the appointment was not scheduled, leading to the resident's social withdrawal. A policy on audiology services was requested but not provided.
A resident with intact cognition and mobility independence was found with an unsecured mattress hanging over the bed frame, lacking a footboard or retainer bar. Despite staff awareness, no documentation or alternatives were provided to address the safety risk. The facility's bed safety policy was not available.
A facility failed to monitor and document the oxygen use for a resident with COPD and respiratory failure, leading to a deficiency in care. The resident's oxygen saturation levels were recorded without noting the liters per minute (LPM) of oxygen administered, despite an order to maintain saturation above 92 percent. The resident experienced worsening shortness of breath and was hospitalized, while the facility's system did not allow for proper documentation of oxygen dosage.
A facility failed to ensure the safety of a resident's bed rails, leading to a deficiency. The resident, who required assistance for bed mobility, had a loose side rail that increased the risk of injury. Despite the resident's concerns, staff did not take corrective action, and the facility's documentation lacked comprehensive assessment and maintenance of the side rails. Interviews revealed a lack of communication and follow-up regarding the issue, and the facility did not have a policy on side rail evaluation and maintenance.
A facility failed to address consulting pharmacist recommendations for a resident on multiple psychotropic medications. The pharmacist recommended reviewing the lowest effective doses, but no response was documented. Interviews revealed a lack of evidence of provider response, and the interim DON was unsure if recommendations were sent to the correct psychiatrist due to recent changes.
A facility failed to document symptoms and non-pharmacological interventions before administering PRN psychotropic medication to a resident with severe cognitive impairment and on hospice care. The resident's records showed multiple administrations of lorazepam without supporting documentation, and staff interviews revealed inconsistent documentation practices. The facility's policy required such documentation to ensure the medication's necessity and efficacy, but this was not adhered to, highlighting a gap in care.
A resident with cellulitis and other conditions did not receive prescribed wound care due to the facility's failure to verify and implement orders from a nurse practitioner. The orders for daily cleaning and Betadine application were not reflected in the treatment records, and staff did not clarify the orders with the provider. The facility lacked a treatment order policy, indicating a procedural gap.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain resident dignity for 2 of 2 residents reviewed when staff did not knock, introduce themselves, or wait for permission before entering resident rooms. R9’s quarterly MDS identified dementia, psychosis, dependence on staff for all cares, and hospice enrollment. R13’s quarterly MDS identified cognitive intactness along with fibromyalgia, anxiety, depression, and chronic pain. During observation and interview, a nursing assistant entered the shared room occupied by R9 and R13 without knocking or announcing herself, wheeled R9 into the middle of the room, and left without speaking. The same two nursing assistants later entered the room again without knocking. Both staff members confirmed they did not knock, introduce themselves, or wait for permission to enter. R13 stated that most staff failed to knock and wait to enter her room and described an incident where a staff member looked into the room while she was naked without knocking or introducing herself. The DON stated the expectation was for all staff to knock and wait for permission before entering any resident room.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not ensuring a call light was accessible for one resident reviewed for call lights. The resident had impaired cognition, no limitation in upper extremity range of motion, and was dependent on staff for turning, repositioning, transfers, and all personal care. The resident’s diagnoses included dementia, and the resident was enrolled in hospice. During observation, a nursing assistant wheeled the resident into the middle of the room and left without placing the call light within reach or speaking to the resident. On another observation, the resident was lying in bed with the head of the bed elevated and pillows positioned around the body, while the call light was attached to the bed sheet under a pillow, hanging down to the bed frame and out of sight. The nursing assistant stated the resident was able to use the call light and acknowledged that call lights should be in reach of residents if they need assistance. The DON stated every resident should have a call light in reach and that it is their lifeline to ask for help if needed. Facility policy stated call cords, buttons, or other communication devices must be placed where they are within reach of each resident.
Failure to Provide Transfer Notice and Bed-Hold Information
Penalty
Summary
The facility failed to provide a written transfer notice and notice of bed hold for 1 resident who was transferred to the emergency room for diarrhea. The resident’s admission MDS identified impaired cognition, need for assistance with all personal cares, and diagnoses of hemiplegia, diabetes, and anxiety. The resident’s EMR progress notes did not show a hospitalization or emergency room visit since admission, although a hospital after-visit summary dated 4/14/26 identified the transfer to the ER for diarrhea. During interviews, the resident could not recall whether a transfer form or bed hold notice was offered or provided at the time of the ER visit. The RN who sent the resident to the hospital stated he believed he had called and left a message with the guardian but did not document it. Facility staff stated the nurse was expected to offer and provide a signed transfer form and bed hold notice, document that in the EMR, and follow up until contact was made. The DON verified the resident’s EMR did not contain a transfer form or bed hold notice and that the facility failed to follow up on obtaining it. The facility policy titled Bed-Holds and Returns required written information be given prior to transfer explaining bed-hold rights and limitations, reserve bed payment policy, per diem rate requirements, and transfer details.
Failure to Care Plan Polydipsia and Fluid-Seeking Behaviors
Penalty
Summary
The facility failed to develop and implement, or revise as needed, a comprehensive, person-centered care plan with individualized interventions for a resident with polydipsia and ongoing fluid-seeking behaviors. The resident had severe cognitive impairment and a diagnosis of polydipsia. The care plan, dated 10/29/24, noted that a risk versus benefit form was completed for not following the recommended diet related to polydipsia and documented that the resident was observed trying to get drinks from other residents and drinking water from the bathroom sink. It also included an 1800 milliliter fluid restriction and instructions to offer fluids and snacks between meals, but it lacked updated, resident-specific interventions to reduce fluid-seeking behaviors and increase comfort related to polydipsia despite continued repeated attempts to obtain more fluids. Record review and staff interviews showed the resident's April 2026 TAR tracked fluid intake and fluid-seeking behaviors but did not include resident-specific interventions. During observation, the resident was pacing between the room and hallway and asking to get into the bathroom, while a sign on the door directed staff to keep the door closed and not allow access to the bathroom. Staff stated the bathroom door remained locked to prevent the resident from drinking from the sink, and one staff member said the resident needed more reminders. Nursing staff reported the resident frequently requested fluids, was given thickened liquids in small cups, and was managed with frequent redirection, pudding, ice cream, supplements, one water jug per shift, a closed bathroom door, and a commode. The nurse manager and DON acknowledged that the resident's polydipsia was not specifically care planned, and that interventions such as lemon oral swabs had not been trialed, while the behavior was only documented in the nutrition section of the record.
Incomplete BIPAP Orders and Missing Respiratory Settings Documentation
Penalty
Summary
The facility failed to ensure accurate and complete respiratory care documentation and resident-specific ordered settings for the use and management of a BIPAP device for one resident. The resident’s quarterly MDS indicated intact cognition with a BIMS score of 14 and use of a non-invasive mechanical ventilator. Physician orders directed the BIPAP to be applied at bedtime, remain on during nocturnal hours, and be removed in the morning, along with daily water changes and weekly cleaning of the water chamber, mask, and tubing. However, the orders did not include specific BIPAP settings or clear direction for staff to verify or maintain the prescribed settings. During interviews, an RN stated that BIPAP machines typically arrived pre-set and staff were instructed not to adjust settings unless there was a malfunction, while nurses checked the machine to ensure settings remained as originally set. A nurse manager stated that when a BIPAP was ordered, the facility typically faxed the order to a respiratory company for setup and that staff were expected to have specific settings documented in the orders. She also stated she was unable to locate documentation identifying the respiratory company responsible for setup or the specific BIPAP settings for the resident, and that this resident was the only one for whom this information could not be found.
Failure to Document Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented before administering PRN pain medications for 2 residents, R5 and R28, who were reviewed for unnecessary medication use. For R5, the admission MDS identified intact cognition, no hallucinations, delusions, or behavioral issues, and noted that the resident received scheduled and PRN pain medications without non-medication interventions. R5 reported occasional pain rated 4 out of 10, and the care plan included non-medicinal pain relief such as positioning, rest, and massage, along with pain medication as ordered and documentation of effectiveness. R5’s MAR/TAR showed multiple administrations of hydrocodone-acetaminophen and methocarbamol for pain, with documentation of pain scales and effectiveness, but no documentation that nonpharmacological interventions were offered or attempted before the PRN medications were given. Progress notes and the medical record also lacked evidence of any non-medication interventions prior to the administered doses. During observation, R5 was given hydrocodone-acetaminophen and methocarbamol while lying in bed, and stated that staff sometimes offer alternatives such as placing a pillow underneath him to help reposition him, but this was not documented for the reviewed administrations. For R28, the MDS indicated intact cognition with a BIMS score of 15 and receipt of PRN pain medication, but no non-medication pain interventions. The care plan listed non-pharmacological pain interventions such as positioning, rest, massage, and other comfort measures, yet the record lacked resident-specific documentation of what interventions were attempted, what was effective, or what was ineffective. R28 received multiple doses of methocarbamol in April, and the MAR/TAR contained no corresponding documentation of non-pharmacological interventions before administration. Interviews with nursing staff and the DON confirmed the expectation that non-pharmacological interventions should be offered and documented prior to or with PRN pain medication use, and the facility policy stated nursing would evaluate appropriate non-pharmacological interventions to address pain.
Failure to Maintain Bedroom Ceiling Lights
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for 2 residents whose main bedroom ceiling lights did not function properly. R9’s quarterly MDS identified impaired cognition, no limitation in upper extremity range of motion, and dependence on staff for turning, repositioning, transfers, and all personal care; R9 also had dementia and was enrolled in hospice. R13’s quarterly MDS identified intact cognition and diagnoses of fibromyalgia, anxiety, depression, and chronic pain. During observation, R13 pointed to a flickering ceiling light and stated it had not worked for a long time. R13 said the strobe-like light caused headaches and that she had to use the pull-string light over her bed because the room was otherwise dark. A NA stated staff were expected to use the TELS electronic messaging system to request maintenance repairs and said she was aware that R9 and R13’s ceiling light had not worked for at least a month. The DON and MT-D both stated maintenance requests were to be submitted through TELS, and the MT-D verified that no TELS requests had ever been submitted for the two residents’ ceiling light issue.
Improper Cleaning of Glucometers in LTC Facility
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of community-use glucometers between patient uses, as well as failed to ensure that staff were knowledgeable about the correct procedures for cleaning and disinfecting these devices according to the manufacturer's instructions. This deficiency had the potential to affect nine residents who were diabetic and required blood glucose monitoring using a community glucometer. The manufacturer's instructions for the Arkray Assure Platinum Blood Glucose Monitoring System specify that the device should be cleaned and disinfected with an EPA-registered wipe, such as the Super Sani-Cloth Germicidal Disposable Wipes, which require a contact time of two minutes to be effective. During observations, it was noted that registered nurses and other staff members did not follow the manufacturer's instructions for cleaning and disinfecting the glucometers. For instance, RN-A used hand sanitizer on a facial tissue to clean the glucometer instead of the recommended Saniwipe, and did not allow the device to remain wet for the required contact time. Similarly, RN-C used a Saniwipe but did not adhere to the recommended contact time, and LPN-B incorrectly stated that alcohol wipes could be used for cleaning the glucometer. Additionally, staff did not wash residents' fingers with soap and water before obtaining blood samples, as required by the manufacturer's guidelines. Interviews with various staff members, including the assistant director of nursing and the facility's infection control preventionist, revealed inconsistencies in the understanding and implementation of the correct cleaning procedures. The facility's policy on cleaning and disinfecting medical equipment was requested but not provided, indicating a possible lack of formalized procedures or training. This lack of adherence to proper infection control practices could potentially lead to the transmission of blood-borne pathogens among residents using shared glucometers.
Unfinished Wall Repair in Resident Room
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for two residents sharing a room with an unfinished wall. The wall had a large area of white joint compound that was unsanded and unpainted, which had been in this state since one of the residents moved into the room in October 2024. Both residents expressed dissatisfaction with the appearance of the wall, stating it made the room feel unclean and uncared for. Despite the residents' intact cognition, the issue was not addressed by the staff, who were expected to notify maintenance for repairs. Interviews with various staff members, including registered nurses, nursing assistants, and the maintenance director, revealed that none had noticed the unfinished wall or submitted a maintenance request to complete the repair. The maintenance director acknowledged the patching work but cited a lack of available rooms to relocate the residents temporarily and the absence of matching paint as reasons for the delay in completing the repair. The facility's policy on building maintenance and repair was requested but not provided, indicating a possible lapse in procedural adherence.
Failure to Provide Dentures for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident, identified as R60, was provided with necessary dental appliances to promote safety and independence in eating. R60, who had severe cognitive impairment and was dependent on staff for oral hygiene, was observed without dentures on multiple occasions. Despite having a care plan that indicated the use of dentures, there was no evidence that R60 was offered or refused his dentures during the observed days. Nursing staff, including a nursing assistant and a registered nurse, were unaware of the presence of R60's dentures, which were found in his room, and did not offer them to him during morning care. The interim director of nursing confirmed that R60 had dentures and acknowledged that refusals to wear them were not documented. The facility's policy on maintaining abilities in activities of daily living emphasized the importance of providing necessary care to prevent a decline in residents' abilities unless unavoidable. However, the lack of documentation and awareness among staff regarding R60's dentures led to a failure in providing appropriate care, as dentures were not offered or placed before meals, which is essential for the resident's ability to eat properly.
Failure to Provide Routine Nail Care for Resident
Penalty
Summary
The facility failed to provide routine nail care for a resident who required assistance with activities of daily living (ADLs). The resident, who was cognitively intact and did not refuse care, had long, yellow fingernails with dark orange matter underneath and a cracked toenail with a sharp edge. Despite the resident's need for assistance with personal care, as indicated in their care plan and clinical diagnosis report, the facility did not provide the necessary nail care. The resident expressed dissatisfaction with the lack of assistance, stating that it had been at least a month since staff helped with nail care. Observations and interviews revealed that the facility's staff, including nursing assistants and a nurse manager, were responsible for trimming residents' nails on bath days. However, the resident's weekly skin assessments inaccurately indicated that nail trimming was not needed. The assistant director of nursing acknowledged the importance of nail care for infection control and preventing skin problems, but the facility's failure to provide this care resulted in the deficiency. The facility's policy on activities of daily living emphasized the need for necessary services to maintain grooming and personal hygiene, which was not adhered to in this case.
Failure to Address Wheelchair Posture and ROM Interventions
Penalty
Summary
The facility failed to adequately assess and address the wheelchair posture of a resident with severe cognitive impairment and functional limitations in range of motion. The resident was observed multiple times seated in a standard wheelchair with poor posture, as his arms could not rest on the armrests without hunching his shoulders. The wheelchair was in disrepair, with worn-down wheels exposing the underlying material. Despite these observations, the resident's care plan did not include specific interventions for wheelchair positioning, and there was no evidence of recent evaluation by occupational therapy to address these issues. Another resident with severely impaired cognition and limited range of motion was not provided with the necessary interventions to prevent skin injury and contracture worsening. The resident's care plan included the use of palm protectors and positioning of elbows with towels or pillows, but these interventions were not consistently implemented. Observations revealed the resident lying in bed with hands balled into fists and no protective devices in place. Nursing staff were unaware of the need for these interventions and did not document any refusals or alternative measures. The facility's failure to communicate and implement assessed interventions for both residents highlights a lack of coordination between nursing and therapy services. Staff interviews revealed a lack of awareness and follow-through on necessary interventions, leading to inadequate care for residents with mobility and positioning needs. The facility's policies did not provide clear guidance on when to refer residents to therapy services for ongoing concerns, contributing to the deficiencies observed.
Failure to Schedule Audiology Consult for Resident
Penalty
Summary
The facility failed to act promptly on an order for an audiology referral for a resident who expressed difficulty with hearing. The resident, who had intact cognition and no delusional thinking, was noted in a quarterly Minimum Data Set (MDS) to have adequate hearing and did not use hearing aids. However, a referral form dated February 22, 2024, indicated an order for an audiology consult due to a diagnosis of hearing loss. By July 1, 2024, the resident reported worsening hearing loss, leading to social withdrawal, and the provider's note reiterated the need for an audiology consult. Interviews revealed that the interim Director of Nursing (DON) directed questions about resident appointments to the Health Information Manager (HIM), who confirmed that the audiology appointment had not been scheduled or refused by the resident. The HIM acknowledged the oversight and stated that scheduling the appointment would now take about four months. A policy regarding audiology services was requested but not provided, indicating a lack of documented procedures for ensuring timely access to necessary medical consultations.
Failure to Secure Bed Mattress for Resident
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R59, by not assessing and securing the bed mattress properly. R59, who had intact cognition and was independent in most mobility-related activities, was observed with a mattress that hung over the foot of the bed frame by about 12 inches, lacking a footboard or retainer bar to prevent it from sliding. The resident expressed difficulty in getting on and off the bed and mentioned that the footboard was removed and placed in the closet by staff. Despite being aware of the issue, the maintenance director and nursing staff did not document or offer alternatives to address the overhanging mattress. Interviews with various staff members, including a nursing assistant, RN, LPN, and the assistant director of nursing, revealed a lack of communication and documentation regarding the resident's bed safety. The maintenance director acknowledged the availability of bed extensions and longer mattresses but did not document any efforts to provide these alternatives. The facility's failure to assess and document the appropriateness of the mattress and bed frame for R59, who was at risk for pressure ulcers, was evident. The facility's policy on bed safety was requested but not provided, indicating a potential gap in procedural adherence.
Failure to Monitor and Document Oxygen Use
Penalty
Summary
The facility failed to ensure ongoing monitoring of a resident's oxygen use, which led to a deficiency in respiratory care. The resident, who had intact cognition and was diagnosed with heart failure, kidney failure, COPD, and respiratory failure, was on oxygen therapy and had a care plan indicating the need for monitoring and documentation of her respiratory status. However, the facility's medication and treatment records did not document the liters per minute (LPM) of oxygen being administered, despite an order to maintain oxygen saturation above 92 percent. This lack of documentation made it difficult to correlate the oxygen saturation levels with the oxygen dosage being administered. The resident experienced shortness of breath and was observed receiving oxygen at a rate of four LPM, which was not documented in the medical record. The registered nurse confirmed that the computer system did not allow for documentation of the LPM of oxygen administered, and the interim director of nursing acknowledged that the order for recording the oxygen flow rate had been missed. The resident's condition worsened, leading to hospitalization, and the facility was unable to provide a policy regarding oxygen use when requested.
Failure to Maintain Safe Bed Rails for Resident
Penalty
Summary
The facility failed to accurately assess and maintain the safety of side rails for a resident, identified as R33, who used bilateral quarter-sized side rails on their bed. R33's admission Minimum Data Set (MDS) indicated that the resident had intact cognition and required substantial assistance for bed mobility. During an observation, it was noted that the side rail on the open side of R33's bed was loose, allowing significant movement and increasing the risk of entrapment or injury. Despite R33 expressing concerns about the loose rail to staff, no corrective action was taken, and the resident was not informed of alternative options to assist with bed mobility. The facility's documentation, including the Monarch Healthcare Management (MHM) Bed Mobility Device Evaluation, lacked comprehensive information on the assessment of alternative devices for R33. The evaluation incorrectly identified the use of grab bars instead of side rails and did not specify which devices had been attempted or discussed with the resident. Additionally, R33's care plan did not include any information or direction regarding the use of side rails, despite the resident being at risk of falls and injury due to mobility issues. Interviews with staff revealed a lack of communication and follow-up regarding the maintenance of the side rails. Nursing Assistant (NA)-A acknowledged the loose rail but had not reported it for maintenance. The Director of Maintenance (DOR) confirmed that no maintenance requests had been submitted prior to the surveyor's inquiry. The interim Director of Nursing (DON) admitted that the evaluation was completed in error and that the rented bed limited alternative options. The facility did not have a policy on side rail evaluation and maintenance, contributing to the oversight in ensuring the safety of the resident's bed rails.
Failure to Address Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations were fully addressed or acted upon for a resident reviewed for unnecessary medications. The resident, who had intact cognition, was diagnosed with major depressive disorder, bipolar disorder, and an anxiety disorder. The resident was prescribed multiple psychotropic medications, including quetiapine, bupropion XL, duloxetine, lamotrigine, aripiprazole, melatonin, and buspirone. The consulting pharmacist made recommendations on two occasions, in December and January, for the prescriber to review whether the resident was on the lowest effective doses of these medications. However, the recommendations were left unaddressed, with no signature, date, or prescriber response documented. Interviews with the consulting pharmacist and the interim director of nursing revealed that there was no evidence of a provider response to the pharmacist's recommendations. The consulting pharmacist noted the importance of attempting to reduce psychotropic medication use when possible, and the interim director of nursing confirmed that the recommendations should have been sent to the resident's psychiatrist. However, due to a recent change in psychiatrists and oversight by the previous director of nursing, it was unclear who the recommendations were sent to. The facility's Medication Regimen Review policy required that pharmacist recommendations be acted upon and documented, but this was not followed in this case.
Failure to Document Symptoms and Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or documented for a resident (R2) before administering as-needed (PRN) psychotropic medication. R2, who had severe cognitive impairment and was on hospice care, was observed to have been administered PRN lorazepam multiple times without documentation of symptoms or behaviors justifying its use, nor any attempts at non-pharmacological interventions. The resident's care plan indicated a history of refusing care and medications, and a risk for adverse reactions to psychotropic medications, yet the facility did not adhere to the outlined protocols. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2025 showed five administrations of PRN lorazepam, each lacking documentation of symptoms or non-pharmacological interventions. Interviews with staff, including a trained medication aide and a registered nurse, revealed that while non-pharmacological interventions were sometimes attempted, they were not consistently documented. The registered nurse acknowledged the absence of recorded symptoms or interventions and suggested that staff might have been administering the medication without proper documentation. Further interviews with the regional nurse consultant and the consulting pharmacist confirmed that the facility's policy required non-pharmacological interventions to be attempted and documented before administering PRN psychotropic medications. However, the resident's medical record lacked the necessary behavior monitoring order set, which should have been used to document interventions and support medication use. The facility's failure to document symptoms and interventions contravened its own policy and highlighted a gap in ensuring the efficacy and necessity of PRN psychotropic medication for the resident.
Failure to Verify and Implement Wound Care Orders
Penalty
Summary
The facility failed to verify and implement wound care orders for a resident with a primary diagnosis of cellulitis of the right lower limb, along with other conditions such as venous insufficiency, muscle weakness, chronic kidney disease stage three, and anemia. The resident's medical records showed that a nurse practitioner had ordered daily cleaning and Betadine application for a vascular ulcer on the resident's right side. However, these orders were not reflected in the treatment administration record for July 2024, indicating a lapse in following the prescribed treatment plan. Interviews with facility staff revealed a breakdown in communication and verification processes. The registered nurse and clinical manager described a procedure where the wound care nurse and clinical manager would update treatment plans based on the wound care provider's notes. However, the clinical manager assumed the orders were a mistake and did not verify them with the nurse practitioner. The nurse practitioner confirmed that the facility staff did not clarify the orders with her, and the administrator stated that her expectation was for staff to follow and clarify orders as needed. The facility did not provide a treatment order policy when requested, highlighting a potential gap in their procedural documentation.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Bloomington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Martin Luther Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Presbyterian Homes Of Bloomington | 1.8 mi | ★★★★★ | 1 | 0 |
| The Villas At Richfield | 1.9 mi | ★★★★★ | 11 | 0 |
| Aurora On France | 4.2 mi | ★★★★★ | 13 | 0 |
| Edenbrook Of Edina | 4.2 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.