The Villas At New Brighton
Inspection Findings
F-Tag F0554
F 0554
stored on a central medication cart or in the medication room.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Villas at New Brighton
825 First Avenue Northwest New Brighton, MN 55112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and document review, the facility failed to report to the State Agency (SA) a serious bodily injury that resulted from the improper use of a full mechanical lift for 1 of 4 residents (Resident R1) reviewed for falls.Findings include:The Minnesota Adult Abuse Reporting Center did not contain any facility reported incidents related to Resident R1's reported fall from full mechanical lift with subsequent femur fracture on 8/29/25.Resident R1's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated intact cognition with diagnoses which included colon cancer, fracture of left humerus and hemiplegia.Nursing progress notes identified on 8/29/25 at 9:45 p.m., 2 staff members were transferring Resident R1 from his bed to a shower chair with a full mechanical lift. During the transfer, one loop of the sling handle came off of the lift hook, Resident R1's right leg slid out of the sling and Resident R1 landed on the floor in a sitting position then ended on his back. The administrator, director of nursing and on-call provider were notified. Resident R1 was transported to the hospital for evaluation and had subsequent surgery for a left femur fracture. During an interview on 9/9/2025 at 3:23 p.m., the administrator stated Resident R1 falling from the lift was determined to not be the result of abuse, neglect, exploitation, or misappropriation so it was not reportable. It was an accident.During an interview on 9/10/2025 at 12:14 p.m. after reviewing incident video, the director of nursing stated the nursing assistants were not following manufacturer's instructions when they attached the sling to the lift prior to transferring Resident R1. Resident R1 fell from the sling because the sling came off the lift hook. Review of facility policy titled The abuse prohibition/Vulnerable Adult Policy dated 4/2025, instructed incidents to be reported including all serious injuries that were determined to be a result of abuse, neglect, exploitation, or misappropriation, even those considered accidental. Examples of serious injury include but were not limited to falls with major injury (including fractures, closed head injury, internal bleeding and death), burns, medication errors with adverse effects or potential for adverse effects, or other resident incidents.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Villas at New Brighton
825 First Avenue Northwest New Brighton, MN 55112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
instructions for proper sling attachment during the transfer. DON confirmed the lower right sling loop was placed at the top of the hook instead of the lower part of the hook. Two attempts were made to contact NA-B with no return phone call.The manufacturer full body sling instruction manual undated, identified the sling was correctly attached to the lift when the loops of the sling were placed at the bottom of the hooks.
The manual warnings include: if the sling is not properly applied, personal injury and damage to the sling could occur.The facility mechanical lift competency instructs: Attach the sling to the lift assuring that the loops are secured to the hooks.Review of facility policy titled The facility safe resident handling program policy undated, instructed when residents received care require assistance from facility to move, assistance was provided in a manner that was safe to both the resident and employee. The facility implemented the following actions prior to the survey which were verified through interview and document review and therefore the IJ was issued at past non-compliance:Staff involved in the incident were immediately suspended pending investigation.The lift and sling were put out of use.Education included how to identify what size a sling was, where to find a resident's sling size, how to attach the sling to the lift, and what to do if a resident's care plan did not identify sling size or if the proper sling size was not available. All nursing staff were competency tested on use of the full mechanical lift.Any staff that had not completed the education or competency test would be required to complete both at the start of their next scheduled shift.
Event ID:
Facility ID:
If continuation sheet
THE VILLAS AT NEW BRIGHTON in NEW BRIGHTON, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NEW BRIGHTON, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE VILLAS AT NEW BRIGHTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.