The Estates at Excelsior: DON Fought Resident - MN
That nursing assistant had worked in the field for 20 years. She said she had never, in all that time, witnessed a staff member fighting and cussing with a resident. She lied anyway, because the person who had done it was her boss.
The incident happened on November 14, 2025, in a shared room where two residents had been having a dispute over space. The director of nursing, referred to in inspection records by her title, DON, brought a third resident into the room to discuss the conflict. What happened next became the subject of sharply different accounts, all of them pointing toward the same outcome: a resident with a bruise on her chest, a director of nursing terminated from her job, and a facility that did not report suspected abuse to the state for more than two days.
The DON's own account, given to inspectors on November 25, described the situation escalating when she moved a tray table that had been pushed into a roommate's space. The resident, identified in inspection records as R1, pushed the table back. When the DON moved it a second time, she said, R1 lunged at her and bit her elbow. The harder the DON told her to stop, she said, the harder R1 bit. The DON said she pushed R1 to a sitting position on the bed, but R1 stood up again. At that point, the DON asked her, "You want to fight me?"
She told inspectors she was angry and in a lot of pain. She acknowledged she should have left the room. "I got upset," she said.
The nursing assistant who walked in on the scene described something different. She entered the room and saw the DON hitting R1. She separated them. The DON walked toward the door. Then the DON came back, pushed R1 down onto the bed again, and started fighting with her. It took two staff members to pull the DON off the resident.
A third resident who had been brought into the room to mediate the dispute ran out frightened. That resident told inspectors she saw the DON move R1's table, saw R1 standing behind her shaking her fist, and then saw R1 run up and start biting the DON. She fled before seeing what happened next.
The accounts share one thing in common: the DON's hands were on a resident.
What followed the incident was, by the administrator's own account, a slow and muddled response. He told inspectors he reached out to his supervisor after the incident and was instructed to have the DON fill out a workers' compensation form. He had the third resident transferred to another room for safety. He spoke with police, who offered to transport R1 to a hospital but noted there would be a delay, and ultimately had no concerns of their own.
He said he interviewed the nursing assistant and a licensed practical nurse but found what they told him unclear. He did not interpret what they were saying as an indication of rough handling by the DON. He did not receive the DON's written statement until November 17.
It was not until November 16, when he spoke again with the nursing assistant, that he told his supervisors to escalate the investigation. The DON was suspended that day. A skin assessment was ordered, and a small bruise was found on R1's chest. The administrator reported his findings to the state that evening, at 6:54 p.m.
That was more than 48 hours after the incident occurred.
The facility's own abuse policy, dated April 20, 2025, required suspected abuse to be reported to the state no later than two hours after the incident. It also required staff who witness abuse to notify their supervisor immediately, and required the immediate suspension of any alleged perpetrator who was a staff member.
The nursing assistant said she felt intimidated by the DON, which is why she did not tell the truth in her first written statement. She corrected her account before inspectors completed their review.
A registered nurse who spoke with R1 after the incident said the resident became anxious when she thought she heard the DON nearby. The nurse told R1 the DON was not at the facility. She told inspectors that if she had been present during the incident, she would have reported the DON's actions to the administrator immediately.
R1 apologized to the DON after speaking with police. The DON mentioned this to inspectors.
Federal inspectors cited the facility for abuse at the level of immediate jeopardy, the most serious finding available under the inspection system, meaning inspectors determined the situation had placed residents at risk of serious harm or death. The immediate jeopardy citation began on November 14, the day of the incident, and was not removed until November 17, after inspectors verified the facility had re-educated all staff on what constitutes abuse and when to report it, and after the DON had been suspended and then terminated.
The administrator's account raises a question the inspection report does not fully answer: what exactly did the nursing assistant and the licensed practical nurse tell him in the hours after the incident that he did not interpret as rough handling? He said it was unclear. He said he did not see it as an indication of a problem. Two days later, after a second conversation with the nursing assistant, he escalated immediately.
What changed in that second conversation is not recorded in the inspection documents.
What is recorded is that a woman who had worked in nursing homes for two decades saw her supervisor fight a resident, wrote down a version of events that wasn't true because she was afraid, and eventually told inspectors what she had actually seen. A bruise was found on a resident's chest. The director of nursing who had been responsible for the care and safety of every resident in that building was fired.
R1, who bit the DON hard enough to break skin and who was later found to have a bruise on her chest, still lives at the facility. After the police came and spoke with her, she said she was sorry.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Estates At Excelsior LLC from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
The Estates at Excelsior LLC in EXCELSIOR, MN was cited for violations during a health inspection on November 26, 2025.
That nursing assistant had worked in the field for 20 years.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.