For the second time this year, a large Twin Cities nursing home with a troubling health and safety record has been ordered to pay more than $1 million in damages for failing to protect residents from serious harm.

A jury found this month that the Estates at St. Louis Park, a 175-bed nursing home, was responsible for the 2018 choking death of a 62-year-old man with a swallowing disorder. Just months earlier, a separate jury reached a similar conclusion about a man with dementia who fell from a third-story window at the nursing home. Ronald Lund, now 86, fractured his spine and is permanently disabled — unable to stand or walk on his own. Juries concluded that the Estates was negligent in both cases and ordered the nursing home to pay a total of $2.3 million to victims and their relatives.

The large verdicts point to deeper safety concerns at the nursing home, which is run by a for-profit company and has repeatedly put its vulnerable residents in harm's way, according to federal records.

They also raise fresh questions about whether state and federal regulatory measures go far enough in protecting vulnerable residents. The COVID-19 pandemic exposed unsafe conditions in many of the nation's 15,000 nursing homes, prompting the Biden administration to propose an ambitious plan that would establish minimum staffing levels and hold poorer-performing facilities more accountable through stiffer fines and other penalties. Poor infection controls and lax oversight have been linked to many of the more than 200,000 COVID-related deaths in the nation's nursing homes.

"Facilities like [the Estates] are 'Exhibit A' of why our nursing home enforcement system needs to be strengthened," said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy in Washington, D.C. "We are far too tolerant of poor care."

The devastating incidents at the Estates also reflect the dearth of options that many families face when they are searching for a safe place for their aging loved ones. Often families have to make these critical decisions in periods of distress, after a parent or other relative has suffered a debilitating medical emergency. Sometimes they have just days or even hours to decide — and are pressured to accept recommendations by discharging hospitals. These pressures have been exacerbated by a dwindling workforce: An industry survey this spring found that 78% of Minnesota's nursing homes are limiting admissions because of staffing constraints.

Left with few options and little time, many vulnerable seniors end up at substandard facilities with poor safety records. Minnesota has 351 skilled nursing homes, and nearly 20% of them have the lowest possible rating of one star ("much below average") for health inspections on the federal government's five-star rating system.

The federal Centers for Medicare and Medicaid Services, which oversees nursing homes, has been aware of health and safety problems at the Estates for years, and has chronicled the problems in its inspection reports. The nursing home has been cited nearly 50 times for violating federal health standards since early 2018, records show. It was also fined nine times for a total of $136,000. As a result of these deficiencies, the Estates earned just one star for overall care on the federal government's rating system.

In a survey last March, inspectors found the Estates failed to provide proper respiratory care for two residents who relied on tracheostomy tubes to breathe. One of these residents died after staff failed to clean her airway properly, surveyors found. Another resident was found to be in "immediate jeopardy" of serious illness or death as a result of the inadequate care, the report said. Two nurses told inspectors they did not recall being trained on what to do in case of emergencies with tracheostomy tubes, the report said. After being told of the unsafe practices, administrators at the Estates implemented a plan to correct them, the report said.

Panda Olson, whose father fell from the facility's third floor, said Lund was sent to the nursing home in March 2020 on a short-term basis to rehabilitate from an infection. But Olson said she was was "horrified" by conditions at the Estates when she visited soon after his admission. At the time, staff were unable to identify Lund by name or where he was living in the facility, she said. When she finally found her father, he was lying on a bed with no sheets, and was in the same clothes he was wearing when he arrived the previous day.

A few weeks later, Lund fell out a window, hit a tree on the way down and landed on his back in the nursing home's parking lot.

"I honestly don't believe that anybody should be living in that facility," said Olson, a registered nurse who lives in Ham Lake. "But I think that maybe, by winning these verdicts, we can stop this neglect from happening to other families and help ensure that no one else will have to go through this horrible experience."

Monarch Healthcare Management, the Mankato-based company that owns the Estates, declined to comment about the nursing home and its safety record. However, Stephen Laitinen, a St. Paul attorney who represented the the nursing home in the choking death, described it as "an isolated incident" and said the facility had the proper policies and procedures in place.

"We fully recognize this was a tragic event from four years ago, and we do have empathy for the family," he said. "The Estates and Monarch ... are always committed to safety, and they are always trying to improve their systems and their procedures."

In both cases, families and their attorney say, the nursing home failed to heed obvious warning signs that their loved ones were vulnerable and required closer supervision.

On multiple occasions before the fall, Lund demonstrated risky behavior associated with his dementia, according to a civil lawsuit. He talked frequently about needing to leave the facility to find and protect a young child he did not have. Soon after being admitted to the Estates, he escaped from his third-floor memory care unit and was found wandering the facility, the family's lawsuit said. Then, just four days before his fall, Lund opened a window by removing its screws, and was seen by staff yelling at people in the parking lot below, according to a state investigation report.

In April, a jury found the Estates was "negligent in its care and treatment" of Lund and awarded him $1.375 million.

"There were plenty of warning signs that were ignored," said Joel Smith, an attorney with the Kosieradzki Smith Law Firm in Plymouth that represented families in both cases.

A jury also ruled in favor of another resident, Raymond Bigus, 62, who choked to death in September of 2018 despite the facility documenting that he had a swallowing disorder and had dietary restrictions. A civil lawsuit chronicled numerous incidents in which Bigus had difficulty eating, including one in 2016 when he yelled, "I am choking," while eating lunch.

On the afternoon he died, Bigus was found choking during lunch, and staff at the Estates later removed a piece of meat from his mouth.

In court filings, the defense argued that Bigus was "noncompliant" and frequently ate fast food and candy against his ordered diet, didn't wear his dentures regularly while eating, and denied staff offers to cut up his food. Two medical professionals provided expert opinions asserting that the Estates followed proper standards of care, and that Bigus frequently denied care offered to him.

But after a four-day trial, the jury disagreed. They determined the Estates was negligent in its care and responsible for Bigus' death. His family was awarded $1 million in damages.

More important than the monetary damages, family members said, is the hope that the verdicts will lead to substantive changes and improved care at the nursing home.

"Now I know the nursing home has been held accountable and they will have to follow proper safety protocols for every patient," said Mary Bigus, of St. Louis Park, Raymond's former wife. "It's a victory for vulnerable adults and ordinary people everywhere."

Staff writer Kim Hyatt contributed to this report.