Villas at New Brighton: Lift Fall Fracture Unreported - MN
The Villas at New Brighton, a nursing facility at 825 First Avenue Northwest, never reported any of this to the state.
The Minnesota Adult Abuse Reporting Center, when inspectors checked, contained no record of the incident. No report of the fall. No report of the surgery. Nothing.
The administrator's explanation, given to inspectors on September 9, was brief: it was an accident. Because the fall was not determined to be the result of abuse, neglect, exploitation, or misappropriation, it was not reportable.
That determination was wrong. And the facility's own written policy said so.
The resident, identified in inspection records only as R1, had intact cognition. He understood what was happening to him. His quarterly assessment, completed before the fall, documented his diagnoses: colon cancer, a fracture of the left humerus, hemiplegia. He was not a man who could catch himself. He was not a man who could break a fall. When the sling gave way at 9:45 in the evening, he had no way to stop what came next.
Two nursing assistants were performing the transfer. The procedure requires attaching a sling to a full mechanical lift, securing the resident, and moving them safely from one surface to another. It is not a complicated process, but it requires that the equipment be used correctly. On August 29, it was not.
The director of nursing reviewed the incident on video. She told inspectors on September 10, the day of the inspection, that the nursing assistants had not followed the manufacturer's instructions when they attached the sling to the lift before the transfer began. The sling came off the hook because it had not been properly secured. R1 fell because of what the staff did, or failed to do, in the moments before the lift moved.
The administrator knew this. The director of nursing knew this. The on-call provider was notified the same night. And still, in the twelve days between August 29 and the September 10 inspection, no one filed a report with the state.
The facility's own abuse prohibition and vulnerable adult policy, dated April 2025, listed exactly what had to be reported. Falls with major injury. Fractures. The policy did not require that the injury be caused by intentional abuse. It required reporting of serious injuries determined to result from abuse, neglect, exploitation, or misappropriation, and it specified that this included incidents considered accidental. A femur fracture is a major injury. A fall from a mechanical lift is a fall. The policy's own language covered this.
The administrator's position, that the incident fell outside the reporting requirement because it was accidental, does not hold up against the text of the policy the facility had written for itself.
There is a particular weight to what the director of nursing said on September 10. She had seen the video. She knew the sling had not been attached correctly. She knew that R1's leg had slid out because the attachment failed. She knew that the failure was the result of the nursing assistants not following instructions. And yet the facility's official position, maintained for nearly two weeks, was that this was simply an accident, the kind that doesn't require a phone call to the state.
R1's medical history matters here. Hemiplegia means paralysis on one side of the body. A prior fracture of the left humerus means his arm had already been broken once. He was a man whose body had already been through a great deal. A femur fracture, one of the largest bones in the body, is not a minor injury in any patient. In a man with his history, it meant surgery. It meant recovery. It meant more.
The inspection was a complaint investigation, not a routine survey. Someone prompted the visit. The inspectors arrived on September 10 and found what they found: a serious injury, a video showing the cause, a director of nursing who could see in the footage what the nursing assistants had done wrong, and no report anywhere in the state system.
The deficiency was cited at the level of minimal harm or potential for actual harm, which is the lowest tier of the federal harm scale. That classification reflects the regulatory category of the violation, which is about reporting failure, not about the injury itself. The femur fracture happened. The surgery happened. Those are not classified as potential.
What the facility failed to do was make a phone call, or file a report, or take any step to put what happened into the official record that exists so that state authorities can track patterns, investigate if necessary, and know what is happening to residents in the facilities they oversee. The point of mandatory reporting is that the facility does not get to decide, alone and without outside review, whether what happened to a resident rises to the level of something the state should know about. That decision had already been made, in the policy the facility drafted in April 2025, and the facility didn't follow it.
The administrator called it an accident. The director of nursing, after watching the video, described nursing assistants who had not followed instructions. Those two statements exist in the same inspection report, and they do not fully fit together. An accident is something that happens despite correct procedure. What the video showed was something different.
R1 went to the hospital on the night of August 29. He had surgery for a left femur fracture. The inspection closed on September 10. His name is not in the public record. What he went through is.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villas At New Brighton from 2025-09-10 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 29, 2026 · Our methodology
THE VILLAS AT NEW BRIGHTON in NEW BRIGHTON, MN was cited for violations during a health inspection on September 10, 2025.
The Villas at New Brighton, a nursing facility at 825 First Avenue Northwest, never reported any of this to the state.
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.