Presbyterian Homes of Bloomington: Oxygen Doc Failures - MN
The resident, identified in inspection records only as R3, is a woman with encephalopathy, Parkinson's disease, chronic atrial fibrillation, and pulmonary hypertension. Her doctor had ordered supplemental oxygen at one liter per minute via nasal cannula at night, specifically to keep her blood oxygen saturation above 91 percent when she wasn't wearing her CPAP mask. The order did not cover daytime use.
Yet on April 21, 2026, during a care conference with her family, R3 was wearing supplemental oxygen in the middle of the afternoon. Her oxygen saturation at 3:22 p.m. that day was 98 percent. She remained on supplemental oxygen through the morning of April 23.
Her family member, interviewed by inspectors on April 23, said R3 used oxygen at night because she disliked the CPAP mask. As for why she had it on during the care conference that afternoon, the family member didn't know.
Neither did the nurses.
Registered Nurse A, interviewed that same afternoon, said R3 used oxygen at night and when she was resting in bed during the day because she didn't like the CPAP mask. RN-A acknowledged that if a resident needed supplemental oxygen because of low saturations, the right steps were to assess the resident, notify a provider, and write a note. But R3's saturation had been 98 percent, not dangerously low, and no such documentation existed.
A physical therapy note from April 22 showed that when therapists arrived for a session, R3 was on one liter of supplemental oxygen. Her saturation at the start was 96 percent. Therapists removed the oxygen during the session, and she maintained saturations between 96 and 99 percent on room air throughout. The note recorded that. What nursing never recorded was why she had been placed on oxygen during the day in the first place, or whether anyone had assessed her and decided it was warranted.
On April 24, RN-C sat down with inspectors and reviewed R3's progress notes. RN-C confirmed that nursing documentation did not address the reason or clinical assessment behind the daytime oxygen use. RN-C said staff should have updated the provider and either used a standing house order or obtained a new one if daytime oxygen was going to be part of her care. They had not done that.
The director of nursing, interviewed later that same day, said the expectation was clear: staff were to complete a respiratory assessment, use house standing orders, contact the provider as needed, and document everything in a progress note. "Documentation was important for resident safety, continuation of care, and provider review," the director of nursing said.
The facility's own skilled documentation policy, in place since April 2021, required daily individualized progress notes for residents with skilled nursing needs, covering primary diagnoses and other pertinent conditions. R3's pulmonary hypertension, a condition in which elevated pressure in the lung's blood vessels strains the heart, was among her documented diagnoses. Her care plan specifically listed respiratory status as a focus area.
The inspection, triggered by a complaint, rated the harm level as minimal or potential for actual harm, with few residents affected. The violation involved the failure to maintain complete and accurate clinical records reflecting the care actually provided.
What the records could not answer, even after inspectors asked, was a basic clinical question: why was this woman, with a heart and lung condition serious enough to require nighttime oxygen and a CPAP machine, breathing supplemental oxygen in the middle of the day, during a meeting with her family, with a saturation of 98 percent and no documented reason anyone could point to?
R3's family member sat in that care conference and watched. They didn't know why either.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Presbyterian Homes of Bloomington from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PRESBYTERIAN HOMES OF BLOOMINGTON in BLOOMINGTON, MN was cited for violations during a health inspection on April 24, 2026.
The order did not cover daytime use.
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.