The Villas at New Brighton: Lift Sling Failure - MN
The September 2025 inspection, triggered by a complaint, found that the facility had already taken corrective steps by the time inspectors arrived. Because of that timing, inspectors classified the violation as past non-compliance rather than an ongoing threat. The Immediate Jeopardy designation still stood.
Mechanical lifts are used to move residents who cannot bear their own weight, transferring them between beds, chairs, and toilets. The slings that support a resident's body during that transfer are not interchangeable. A sling that is the wrong size, or one whose loops are not properly secured to the lift's hooks, can fail mid-transfer. The facility's own lift manual warned that an improperly applied sling could cause personal injury.
The warning was not followed.
The facility's safe resident handling policy, which has no recorded date, stated that when residents needed help moving, that help had to be safe for both the resident and the staff member providing it. In this case, it was not. The inspection report does not specify how many residents were involved, noting only that few were affected.
What happened next unfolded quickly. Staff involved in the incident were suspended immediately, pending investigation. The lift and the sling were pulled from use. The facility then launched a facility-wide competency push: every nursing staff member was tested on how to correctly operate a full mechanical lift.
The retraining covered the basics that apparently had not held: how to identify the correct sling size for a given resident, where in a resident's records that size would be documented, how to attach the sling loops to the lift hooks, and what a staff member should do if they showed up to provide care and found that a resident's care plan did not list a sling size, or that the right size was not on hand. That last point matters. A staff member who cannot find the right sling faces a choice, and the training was meant to ensure they make the right one.
Any staff member who had not completed both the education and the competency test by the time inspectors arrived was required to finish both at the start of their next scheduled shift. No exceptions.
Inspectors reviewed documents and conducted interviews to verify the facility's account of what it had done. They confirmed the steps were real. That verification is why the Immediate Jeopardy was issued as past non-compliance, meaning the threat to residents had been addressed before the survey team walked in.
That distinction carries regulatory significance. An ongoing Immediate Jeopardy finding, one where the dangerous condition is still present during the inspection, carries heavier consequences and requires the facility to fix the problem before inspectors leave the building. Past non-compliance means the facility acted first. It does not mean the original failure was minor.
Immediate Jeopardy is the most serious citation category in the federal inspection system. It means inspectors concluded that what happened, or what was allowed to happen, was likely to cause serious injury, serious harm, or death.
A sling that separates from a lift hook mid-transfer drops the person suspended in it. For an elderly resident with fragile bones, compromised balance, or limited ability to protect themselves in a fall, the consequences can be catastrophic.
The facility's own manual said so. The loops, the manual instructed, must be secured to the hooks.
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: 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 22, 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 September 2025 inspection, triggered by a complaint, found that the facility had already taken corrective steps by the time inspectors arrived.
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.