The Villas at St. Paul: Resident Preference Failures - MN
Federal inspectors reviewing records from a June 2024 inspection found that a resident identified in reports as R74 was admitted with fully intact cognition. The admission assessment documented no delirium, no disorganized thinking, no altered consciousness, no hallucinations, no delusions, and no behavioral symptoms of any kind. R74 was, by every clinical measure in the record, a person fully capable of stating their own preferences.
The assessment also noted that R74 depended on staff for showering and bathing, which made the question of how they wanted that done more important, not less. Federal guidelines for nursing home assessments are explicit on this point: when a resident can speak for themselves, staff are supposed to ask them directly about their preferences for daily routines and activities, including whether they want a tub bath, a shower, or a bed bath. The preference interview is supposed to be completed during the admission process.
It wasn't completed. Inspectors found the section of R74's assessment that required a bathing preference interview had not been conducted at all.
The violation falls under a federal standard designed to protect what regulators call the right to self-determination, the idea that residents in long-term care facilities retain the ability to shape their own daily lives, particularly around something as personal as how their body is cleaned. The assessment tool inspectors referenced, the Minimum Data Set, exists precisely to capture that kind of information so care plans can reflect what an individual actually wants rather than what is easiest for staff to provide.
For a resident who cannot bathe independently, that distinction matters in a direct, daily way. Whether someone is lowered into a tub, guided into a shower, or washed in bed is not a minor scheduling detail. It involves physical contact, vulnerability, and a degree of dignity that depends entirely on the person receiving care having some say in the matter.
R74 had that say available. The cognition was there. The ability to answer a question about bathing preferences was documented to be intact. The interview simply did not happen.
The Villas at St. Paul is a long-term care facility operating under Medicare and Medicaid certification, which subjects it to federal inspection standards and the requirement that resident assessments be completed accurately and in full. The admission MDS for R74 was dated at the time of admission. The gap inspectors identified was not a matter of a preference changing over time or a resident becoming unable to respond. The interview was flagged as something that should be conducted and then, according to the inspection record, was not assessed.
Inspectors did not document whether R74 was later asked about bathing preferences informally, whether staff had simply been providing whatever bath type was most convenient, or whether R74 had ever raised a concern. The inspection record captures only what the formal assessment showed, and what it showed was an empty field where a resident's answer was supposed to be.
The facility had the information it needed to ask the question. It had a resident who could answer. The assessment form even specified that the interview should happen. What the record does not contain is any indication that anyone sat down with R74 and asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villas At St Paul from 2024-06-27 including all violations, facility responses, and corrective action plans.
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
THE VILLAS AT ST PAUL in SAINT PAUL, MN was cited for violations during a health inspection on June 27, 2024.
Federal inspectors reviewing records from a June 2024 inspection found that a resident identified in reports as R74 was admitted with fully intact cognition.
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.