MINNEAPOLIS, MN - A state health inspection at The Villa At Bryn Mawr revealed multiple care failures, including a resident with severely overgrown toenails who went more than four months without podiatry care despite medical recommendations, and another resident who received no documented range of motion exercises despite being completely dependent on staff for all daily activities.
Months-Long Delay in Essential Foot Care Despite Guardian's Repeated Requests
During the March 2025 inspection, surveyors discovered a resident with hallux valgus (bunion deformity) had visibly elongated toenails extending several millimeters in length. The resident, who wore flip-flops that exposed her feet, told inspectors "I'd like to see the foot doctor again" and stated she couldn't clip the nails herself due to poor balance.
The resident's guardian confirmed they had repeatedly asked the facility to schedule podiatry appointments after noticing the long, thick toenails during visits. However, staff consistently responded with uncertainty about when the podiatrist would be available, telling the guardian "We don't know, we don't know."
Medical records showed the resident's last podiatry visit occurred on November 11, 2024, when the podiatrist documented moderate bunion deformity along with elongated, dystrophic and discolored nails on both feet. The podiatrist explicitly recommended "more frequent podiatry visits to reduce accumulation of hyperkeratotic tissue" and noted that "Non-professional treatment is hazardous to the patient."
Despite these clear medical directives, the resident was not seen during the podiatrist's subsequent visit to the facility on February 13, 2025. The health information manager who coordinated podiatry services could not explain why the resident had been removed from the treatment list, and no documentation existed showing the service had been offered or refused.
Long, untreated toenails in elderly residents create significant health risks beyond discomfort. Overgrown nails can alter gait patterns, increasing fall risk in individuals already experiencing balance issues. The thickened, elongated nails can harbor bacteria and fungi, potentially leading to infections that are particularly dangerous for elderly individuals with compromised circulation. Furthermore, dystrophic nails can curve inward, cutting into surrounding skin and creating open wounds susceptible to serious infections.
Complete Absence of Prescribed Range of Motion Therapy for Stroke Survivor
Inspectors identified another serious care lapse involving a resident who had experienced a stroke resulting in hemiplegia - complete loss of muscle function on one side of the body. Despite being entirely dependent on staff for all activities including dressing, transfers, and bed mobility, the facility provided no documented range of motion exercises.
The resident's care plan, initiated in February 2024, specifically directed staff to "provide gentle range of motion as tolerated with daily care." Physical therapy discharge notes from multiple dates throughout 2024 emphasized that maintaining the resident's current function level required "consistent staff follow-through" with stretching exercises to prevent worsening contractures.
The resident's family member stated during the inspection that "the facility did not provide R63 with continuous range of motion or exercises," so they personally stretched the resident during visits. Nursing assistants interviewed confirmed they had not been instructed to perform any exercises with this resident, with one stating they only provided assistance with exercises when specifically noted in care plans.
The facility's medication administration records and daily care documentation from March 2025 contained no evidence that nursing staff had performed the prescribed range of motion exercises. The director of nursing acknowledged the care plan directed daily range of motion therapy and confirmed the medical record lacked any documentation of these services being provided.
Range of motion exercises are critical for stroke survivors with paralysis to prevent permanent joint contractures - a condition where muscles and tendons shorten and stiffen, fixing joints in bent positions. Without regular stretching and movement, paralyzed limbs can develop severe contractures within weeks, leading to permanent disability, skin breakdown from pressure points, and intense pain. These exercises maintain joint flexibility, preserve any remaining function, and prevent the cascade of complications that arise from immobility.
Kitchen Operations Compromised by Temperature Failures and Sanitation Lapses
The inspection also revealed extensive food safety violations affecting all 98 residents. The facility's dishwashing machine consistently operated at temperatures between 86 and 110 degrees Fahrenheit, well below the manufacturer's minimum requirement of 120 degrees. Staff continued using the machine despite knowing it failed to reach safe temperatures, with one dietary aide stating temperatures of "115 degrees F or below was not safe."
Inadequate dishwashing temperatures fail to eliminate harmful bacteria including E. coli, Salmonella, and Norovirus, which can cause severe gastrointestinal illness. Elderly nursing home residents face heightened vulnerability to foodborne illnesses due to weakened immune systems, with infections potentially leading to severe dehydration, hospitalization, or death.
Inspectors documented numerous food storage violations including opened containers without dates, expired items still in use, and improper storage of thickened liquids critical for residents with swallowing disorders. An opened container of thickened cranberry juice dated ten days past its discard date remained in dry storage, while multiple unlabeled and undated items filled freezers and refrigerators.
Additional Issues Identified
The inspection revealed a pattern of systemic failures extending beyond individual care lapses. Enhanced barrier precautions for infection control were not followed during resident transfers, with staff failing to wear required gowns when providing close-contact care to a resident with a feeding tube. A resident known for frequently throwing dishes in the dining room received no behavioral assessment or intervention plan despite the safety risk to other residents and staff. The facility's first-floor shower room, used by 26 residents, had extensive brown staining on the ceiling that had been present for over a year, with multiple residents expressing concerns about potential mold exposure.
The inspection also documented failures in managing resident behaviors, with one resident regularly throwing plates and food without any systematic assessment of triggers or implementation of preventive strategies. Staff simply accepted the behavior as routine, despite care plans noting the safety risks.
These violations reflect fundamental breakdowns in care coordination and quality assurance systems. The podiatry scheduling system lacked accountability measures to ensure residents received recommended care. Physical therapy recommendations were not translated into actionable nursing interventions. Kitchen operations continued despite known equipment failures that compromised food safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villa At Bryn Mawr from 2025-03-27 including all violations, facility responses, and corrective action plans.
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