Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Delano Llc during CMS and state inspections, most recent first.
Failure to Report AMA Discharges to Ombudsman: The facility did not include two residents who left AMA in the monthly Ombudsman report. One resident left after a LOA and was later found at home after staff made repeated calls, requested a wellness check, and filed MAARC and missing person reports. Another resident with UTI, morbid obesity, weakness, unsteady gait, and falls history was discharged AMA with family after confusion and behavioral concerns; MAARC was filed, but the AMA discharge was not included in the Ombudsman report.
A resident with OSA, chronic respiratory failure, CHF, diabetes, AFib, CKD, ESRD, and asthma had a care plan for CPAP at bedtime, but the EMR lacked orders for nightly CPAP use, cleaning the mask and tubing, or replacing supplies. Staff said the resident used CPAP every night and needed help applying it, yet the mask and tubing were observed with unknown crusty and dried substances, and the RN and DON could not locate CPAP orders in the EMR.
A resident with CHF, diabetes, ESRD, and dialysis needs had no EMR order for Dexcom sensor replacement even though nurses had been changing it and the resident used it for blood sugar checks. The resident also had no order to remove the post-dialysis pressure dressing, and staff were unsure about the dressing removal process; the resident reported removing the dressing herself after dialysis.
A facility failed to document and educate staff on an abuse protection plan for two residents with severe cognitive impairments, leading to an incident where one resident attempted to grope another. The care sheets lacked necessary information, and float pool staff were not adequately informed, resulting in a deficiency in implementing required interventions.
A resident with intact cognition reported a sexual abuse incident involving a nursing assistant, but the facility delayed notifying law enforcement for three days. Staff interviews revealed a lack of awareness of the facility's policy requiring immediate reporting of such allegations. The facility's policy mandates reporting to the State Agency and law enforcement within two hours for incidents involving serious bodily injury, including sexual abuse.
The facility inaccurately submitted staffing data to CMS, failing to report RN coverage for specific dates despite evidence of RN presence. The administrator confirmed the inaccuracy, and no policy for PBJ entries was provided.
Failure to Report AMA Discharges to Ombudsman
Penalty
Summary
The facility failed to ensure the Minnesota Ombudsman Office was informed of residents who discharged against medical advice for 2 of 3 residents reviewed for discharge from the facility. The deficiency involved two residents whose discharges were documented in the medical record and in staff notes, but whose names and discharge reasons were not included in the monthly reports sent to the Office of Ombudsman. One resident had diagnoses including multiple rib fractures from a motor vehicle accident, acute pain from trauma, and muscle weakness. The resident left the facility on a leave of absence and did not return. Staff documented repeated attempts to contact the resident and a friend, a wellness check through 911, a MAARC report, and a missing person report. The resident was later found safe at home and stated he wanted to be discharged AMA from the facility. The assigned ombudsman stated she had received an email about the resident leaving and the MAARC report, but the facility’s monthly report to the Ombudsman Office did not include the resident’s AMA discharge. The second resident had diagnoses including urinary tract infection, morbid obesity, muscle weakness, unsteady gait, and a history of falls. Staff documented confusion, nudity in the hallway, and family concern about the resident’s condition. The family arrived at the facility, spoke with the DON, Administrator, and SSD, and requested discharge AMA despite staff education about the risks. The family signed AMA paperwork and stated they would take the resident to the hospital. A MAARC report was filed. The assigned ombudsman stated she had received an email about the AMA discharge and MAARC report, but the resident’s name and discharge reason were not included in the monthly Ombudsman report. The SSD stated the filter for AMA had not been selected when the reports were run.
Missing CPAP Orders and Unclean Equipment
Penalty
Summary
The facility failed to ensure there were orders and interventions in place for CPAP machine usage for one resident who was cognitively intact and required assistance with all cares. The resident had diagnoses including CHF, diabetes, atrial fibrillation, chronic kidney disease, end stage renal disease, obstructive sleep apnea, chronic respiratory failure, and asthma. The care plan identified an alteration in oxygen/gas exchange and respiratory status related to sleep apnea and chronic respiratory failure, with an intervention for CPAP at bedtime for sleep apnea. The resident’s physician orders dated 11/17/25 did not include orders to wear the CPAP machine at night, clean the CPAP mask and tubing, or replace CPAP supplies. On observation, the CPAP machine was on a pole with the tubing draped over it and the face mask had an unknown brown, crusty substance around the cushion. Later, the tubing was observed draped over the bottom rail of the bed with the mask facing the floor and the headgear on the floor under the bed, and the mask had an unknown dried, white substance on the cushion. The resident stated she wore the CPAP every night and needed staff assistance to put the mask on, but was not sure when the mask and tubing were cleaned. Nursing staff stated the resident wore the CPAP every night and that nurses took care of the machine, while an RN and the DON stated there should be CPAP orders in the EMR but none could be located.
Missing Orders for Dexcom Sensor and Post-Dialysis Dressing Removal
Penalty
Summary
The facility failed to ensure there were orders in place for R16’s Dexcom sensor and failed to ensure there were orders in place to remove the pressure dressing after dialysis. R16’s quarterly MDS identified the resident as cognitively intact, requiring assistance with all cares, and receiving dialysis. Diagnoses included CHF, diabetes, atrial fibrillation, chronic kidney disease, end stage renal disease, obstructive sleep apnea, chronic respiratory failure, and asthma. Progress notes showed nurses replaced R16’s Dexcom sensor multiple times, and the resident stated staff checked blood sugars using the Dexcom sensor. R16’s EMR contained orders to monitor for signs and symptoms of hypoglycemia and hyperglycemia and to check blood sugars four times daily, but it did not contain an order to change the Dexcom sensor every 10 days. The EMR also contained orders to obtain vital signs after dialysis and monitor the site every shift for bruit and thrill, but it did not contain an order to remove the pressure dressing after dialysis. R16 stated facility staff did not remove the pressure dressing from the dialysis fistula site and that she removed it herself the day after dialysis. RN-A, RN-B, and the DON were unable to locate the missing orders, and the DON stated the Dexcom order had not been restarted after a prior hospital admission.
Failure to Document and Educate on Abuse Protection Plan
Penalty
Summary
The facility failed to ensure an abuse protection plan was documented and all staff were educated on the plan for two residents reviewed for sexual abuse. Resident 1 (R1) had severe cognitive impairment with diagnoses including convulsions and Alzheimer's disease, and was identified as a vulnerable adult with a care plan goal of remaining free from abuse. Resident 2 (R2) also had severe cognitive impairment with dementia and was at risk for mood and behavior alterations. An incident occurred where R2 attempted to grope R1 in the common area, which was witnessed by another resident who alerted staff. Staff intervened immediately, separating the two residents and notifying the administrator. The investigation revealed that the nursing assistant care sheets lacked information about keeping R1 and R2 separate until after the incident. Nursing assistants and a trained medication aide, who were part of the float pool and not regularly working at the facility, were not adequately informed or educated about the need to keep R1 and R2 apart. The care sheets and shift reports did not provide the necessary information, leading to a failure in implementing the required interventions to prevent such incidents. The director of nursing confirmed that the intervention to keep R1 and R2 separate was not documented on the current care sheets, and the administrator acknowledged that the instructions needed clarification. The facility's policy directed staff to protect residents from abuse and ensure proper communication across shifts, but this was not effectively executed, resulting in the deficiency.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to law enforcement in a timely manner for a resident with intact cognition who had been residing in the facility for approximately three months. The resident, who had diagnoses including bipolar disorder, anxiety disorder, and post-traumatic stress disorder, reported that a nursing assistant inserted a hand into her vagina during assistance with hygiene care. The incident occurred on the morning of 10/20/24, but the facility did not notify law enforcement until 10/23/24, after the resident requested to file a police report. Interviews with facility staff revealed a lack of awareness regarding the facility's policy on reporting allegations to law enforcement. The social services director and the director of nursing both stated they were unaware of the requirement to report such allegations immediately. The facility's policy, revised in 2/2024, mandates that any reasonable suspicion of a crime, including sexual abuse, should be reported to the State Agency and local law enforcement within two hours if it results in serious bodily injury. Despite this policy, the facility delayed notifying law enforcement, which constitutes a deficiency in their reporting procedures.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of the Federal Fiscal Year 2024. The deficiency was identified through a review of the Payroll Based Journal (PBJ) Report, which highlighted specific dates where the facility allegedly did not have registered nurse (RN) coverage for eight hours per day. However, upon reviewing staffing schedules, it was found that RN staff had indeed worked for at least eight hours on the specified dates. The administrator confirmed this during an interview, acknowledging that the data submitted to CMS was inaccurate. Additionally, the facility did not provide a policy related to PBJ entries by the end of the survey, which contributed to the deficiency.
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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.
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Nursing homes near Delano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gardens At Winsted Llc | 9.4 mi | ★★★★★ | 6 | 0 |
| Park View Health Care Center | 9.5 mi | ★★★★★ | 1 | 0 |
| Haven Homes Of Maple Plain | 9.5 mi | ★★★★★ | 4 | 0 |
| Lake Ridge Care Center Of Buffalo, Inc. | 10.1 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Howard Lake | 10.2 mi | ★★★★★ | 10 | 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.