The Villas At New Brighton
THE VILLAS AT NEW BRIGHTON in NEW BRIGHTON, MN — inspection on September 10, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During observation on 9/9/2025 at 11:31 a.m., the following medication containers were observed on R4's bedside table: tums, Tussin DM, multi vitamin and anti-diarrheal medication.
During an interview on 9/9/2025 at 11:57 a.m., licensed practical nurse (LPN)-A stated R4 could self-administer medication after a nurse set up.
The medications were kept in the nurse's cart. LPN-A confirmed R4 had tums, Tussin DM, multi vitamin and anti-diarrheal medication on her bedside table and R4 did not have a provider order for tums, Tussin DM, or a multi vitamin. LPN-A stated all medication containers should have been kept in the nurse's cart. If a nurse observed a medication container in a resident room, they should ask the resident if the medication can be placed in the nurse's cart and the provider should be notified.
During an interview on 9/10/2025 at 11:33 a.m., R4 stated she had ordered the tums, Tussin DM, multi vitamin and anti-diarrheal medication for herself online a while ago and no staff member had asked her about them. R4 stated she liked to take the tums whenever her stomach was upset and could not remember how often she was taking it.
During an interview on 9/10/2025 at 1:20 p.m., the director of nursing stated a nurse was expected to complete an assessment on a resident who wanted to self-administer medications.
In addition, a provider order is needed for all medications. If a resident was deemed safe to self-administer medication and keep the medication at bedside, the medication should be stored in a safe and secure place where other residents would not have access to them. DON stated a bedside table was not a safe and secure location. DON confirmed R4 could self-administer medication after nurse set up however, was not being done correctly.
Medication bottles should not be left on the bedside table.
When a nurse observed a medication container in a resident's room, they should place the medication in the cart and contact the provider.
Review of the facility policy titled The Self-administration of Medications policy dated 2/2024, indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245164 09/10/2025
The Villas at New Brighton 825 First Avenue Northwest New Brighton, MN 55112
During the transfer, one loop of the sling handle came off of the lift hook, R1's right leg slid out of the sling and 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. 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 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 R1. 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.
245164 09/10/2025
The Villas at New Brighton 825 First Avenue Northwest New Brighton, MN 55112
manual warnings include: if the sling is not properly applied, personal injury and damage to the sling
jeopardy to resident health or the loops are secured to the hooks.Review of facility policy titled The facility safe resident handling safety 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
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.