Cycle 1
Health 2025-04-03 · Fire 2025-04-03
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bloomington, MN
Presbyterian Homes Of Bloomington
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
9889 Penn Avenue South, Bloomington, MN
(952) 948-3000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
1991-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.43
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.90
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.59
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.56
CMS adjusted RN staffing hours
Adjusted total hours
5.34
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
120
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
83.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0266
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.96
Baseline 14.31% · Performance 17.28% · Measure score 8.96 · Achievement 8.96 · Improvement 0
Healthcare-associated infections
10
Baseline 4.87% · Performance 3.84% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
7.95
Baseline 31.78% · Performance 31.19% · Measure score 7.95 · Achievement 7.95 · Improvement 0.34
Adjusted total nurse staffing
6.68
Baseline 4.83 hours · Performance 4.98 hours · Measure score 6.68 · Achievement 6.68 · Improvement 1.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.64% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 394 · Observed rate 8.88% · Lower 95% interval 7.88% |
| Discharge to community | 41.7% |
50.57%
8.9 pts worse
|
Worse than the National Rate · Eligible stays 374 · Observed rate 39.84% · Lower 95% interval 37.42% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.61% |
95.27%
0.7 pts worse
|
Numerator 228 · Denominator 241 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 241 |
| Discharge self-care score | 46.76% |
53.69%
6.9 pts worse
|
Numerator 101 · Denominator 216 |
| Discharge mobility score | 18.52% |
50.94%
32.4 pts worse
|
Numerator 40 · Denominator 216 |
| Pressure ulcers or injuries, new or worsened | 2.9% |
2.29%
0.6 pts worse
|
Numerator 7 · Denominator 241 · Adjusted rate 4.25% |
| Healthcare-associated infections requiring hospitalization | 3.84% |
7.12%
3.3 pts better
|
Better than the National Rate · Eligible stays 216 · Observed rate 0% · Lower 95% interval 1.77% |
| Staff COVID-19 vaccination coverage | 0.68% |
8.2%
7.5 pts worse
|
Numerator 3 · Denominator 441 |
| Staff flu vaccination coverage | 9.07% |
42%
32.9 pts worse
|
Numerator 47 · Denominator 518 |
| Discharge function score | 52.31% |
56.45%
4.1 pts worse
|
Numerator 113 · Denominator 216 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 191 · Denominator 191 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 53.27% |
25.2%
28.1 pts better
|
Numerator 57 · Denominator 107 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0 |
1.7
1.7 pts better
|
1.9
1.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
2.0
2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.3%
2.3 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.3% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.0% |
96.1%
16.1 pts worse
|
95.5%
15.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
3.9%
2.8 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.7% · Q3 8.1% · Q4 6.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.5% |
4.3%
3.2 pts worse
|
11.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.9% · Q3 13.3% · Q4 3.6% · 4Q avg 7.5% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
4.1%
1.8 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.1% · Q3 2.2% · Q4 2.5% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
12.4%
3.2 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 10.6% · Q3 10.9% · Q4 12.5% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.9% |
17.5%
6.4 pts worse
|
16.7%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 27.5% · Q3 21.4% · Q4 21.6% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 37.0% |
22.5%
14.5 pts worse
|
16.3%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 41.6% · Q3 31.6% · Q4 40.1% · 4Q avg 37.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.3% |
18.6%
6.7 pts worse
|
14.9%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.5% · Q3 31.0% · Q4 27.8% · 4Q avg 25.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
2.3%
1.2 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.0% · Q3 5.4% · Q4 2.5% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.6%
1.2 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.0% · Q3 4.8% · Q4 3.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.1% |
24.8%
9.3 pts worse
|
19.8%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 36.2% · Q3 29.5% · Q4 34.8% · 4Q avg 34.1% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.4%
1.5 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.5% · Q3 10.3% · Q4 1.4% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
88.6%
9 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.3% · Q3 98.1% · Q4 97.3% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
14.0%
3.4 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 9.1% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.9%
1 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.2% · Q3 1.0% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
82.7%
2.1 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
23.1%
2.2 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 16.7% · Expected 15.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-03
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-03
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-04-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-03
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-05-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-05-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-26
C · Minimal harm
2023-05-04
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-06-09
C · Minimal harm
2023-05-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-26
C · Minimal harm
2023-05-04
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-06-09
C · Minimal harm
2023-05-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-03
F758 · Pharmacy Service Deficiencies
Health
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 2025-05-06
D · Potential for more than minimal harm
2024-01-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-11
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-05-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-09
C · Minimal harm
2023-05-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-06-09
Penalties and ownership
What sits behind the stars
Ownership
Larson, Duane
Corporate Director · Individual
Lindh, Daniel
Corporate Director · Individual
Lindh, Daniel
Corporate Officer · Individual
Meyer, Mark
Corporate Director · Individual
Meyer, Mark
Corporate Officer · Individual
Phs Management, LLC
Operational/Managerial Control · Organization
Sullivan, Michelle
W-2 Managing Employee · Individual
Wells Fargo Bank, N.a.
5% Or Greater Security Interest · Organization
Wells Fargo Bank, N.a.
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
The Estates at Bloomington LLC
Bloomington, MN
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Martin Luther Care Center
Bloomington, MN
1-star overall rating with 1-star inspections with $25,378 in total fines with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Minnesota Masonic Home Care Center
Bloomington, MN
5-star overall rating with 4-star inspections with $12,649 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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