Villas at New Brighton: Medication Safety Failures - MN
The resident, identified in inspection records only as R4, had Tums, Tussin DM cough syrup, a multivitamin, and an anti-diarrheal medication sitting on her bedside table when inspectors arrived on September 9, 2025. She had intact cognition, according to her most recent assessment. She had a femur fracture, severe obesity, and asthma. She had ordered the medications herself, from somewhere online, some time ago.
Three of those four medications, the Tums, the Tussin DM, and the multivitamin, had no physician order on file. None.
When inspectors interviewed R4 the following morning, she was straightforward about it. She said she liked to take the Tums whenever her stomach was upset. She could not remember how often she was taking it. She said no staff member had ever approached her about the medications on her table.
The licensed practical nurse on the unit, identified as LPN-A, confirmed everything. She confirmed the medications were on the table. She confirmed there were no provider orders for three of them. She said the medications should have been kept in the nurse's cart, and that if a nurse spotted medication containers in a resident's room, they were supposed to ask the resident about them and notify the provider. That had not happened here.
The facility had conducted a self-administration assessment for R4 in February 2025, seven months before inspectors showed up. The assessment cleared her to take medications after a nurse set them up. But the form itself was incomplete. The section requiring a nurse manager or designee to verify that a resident could produce all current medication containers, that those containers matched current prescriptions, and that medications were stored properly, was left unchecked.
The director of nursing, interviewed on September 10, laid out exactly what should have happened. A nurse was expected to complete an assessment before a resident self-administered medications. A provider order was needed for every medication. If a resident was cleared to keep medications at the bedside, those medications had to be stored somewhere safe and secure, somewhere other residents could not reach them. A bedside table, the director of nursing said directly, was not a safe and secure location.
The director confirmed R4 was supposed to be self-administering after nurse setup, but said it was not being done correctly. Medication bottles should not have been left on the table. When a nurse saw containers in a resident's room, the medications were supposed to go into the cart and the provider was supposed to be contacted.
Nobody had done that. Not once, apparently, in however long those bottles had been sitting there.
The inspection was a complaint survey, meaning someone had flagged a concern before inspectors walked through the door. CMS classified the violation at the minimal harm level. In one sense, the classification fits: R4 had intact cognition, she was taking over-the-counter medications she had chosen herself, and there is no indication in the inspection record that she was harmed. Tums and cough syrup are not high-risk drugs.
But the classification captures only part of what the record shows. A resident was managing her own medication regimen, partially outside the facility's knowledge, for an indeterminate period of time. She could not recall how often she was taking the Tums. The facility's own policy required safe storage precisely because unsecured medications in a resident's room are accessible to other residents, some of whom may not have intact cognition, some of whom may wander. The bedside table was visible and reachable.
The self-administration assessment from February 2025 was supposed to be the checkpoint. It existed. It had been filled out. It just hadn't been completed, and the gap it left open, no verified medication list, no confirmed storage arrangement, no provider orders, went unnoticed for months while the bottles sat on the table.
R4 told inspectors she had ordered the medications herself, online, a while ago. No one had asked.
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.
She had intact cognition, according to her most recent assessment.
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.