The Villas At Robbinsdale

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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 timely report an allegation of physical abuse to the state agency (SA) for 1 of 3 residents (Resident R1) reviewed for abusefindings includeR1's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated she was independent with all activities of daily living. Resident R1's undated admission Record identified Resident R1 admitted to the facility on [DATE REDACTED]. Diagnosis included fracture of vertebrae, diabetes, depression and hypertension.Resident R1's care plan dated 11/14/25, identified an alteration in mobility and staff were to assist with transfers and bed mobility. Resident R1's Associated Clinic of Psychology (ACP) visit note dated 11/13/25, indicated a visit was requested due to an increase in confusion and falls. Resident R1 expressed concern for how a staff person moved her around the previous day and spoke of people being in her bed with her. Staff was consulted after session to report psychotic symptoms and clients care concern.

The visit note indicated Resident R1's appearance was unkempt, lying in bed in a facility gown. Head was craned to

the left and Resident R1 lied still during the visit. Resident R1 endorsed pain in the left leg that she said was new. On 11/20/25 at 11:50 a.m., licensed social worker (SW)-A and the administrator were interviewed. SW-A stated Resident R1 told her a staff member had picked her up and threw her on the floor, then picked her up and threw her back on

the bed. SW-A stated Resident R1 reported the allegation Friday morning on 11/14/25, when family member (FM)-A was present. SW-A said she reported the incident to the SA later that evening. SW-A said abuse allegations should have been reported to the SA within two hours but said Resident R1's FM-A said Resident R1 was confused. The administrator said she felt the problem was that FM-A was insistent Resident R1 was confused but said abuse allegations should have been reported within two hours.During interview on 11/20/25 at 1:53 p.m., the ACP- social worker (SW) stated she had been onsite at the facility and was asked to see Resident R1. The ACP-SW said Resident R1 had presented as delusional. She said Resident R1 was in bed during the visit and had been pretty still and reported pain in her leg which she had attributed to the way staff had moved her around the previous day.

The ACP-SW said she reported the care concern and to LSW-A.During interview on 11/20/25 at 2:40 p.m., LSW-A stated she had spoken to the ACP-SW after her session with Resident R1. LSW-A said she did not report the concern about pain to anyone because the ACP-SW said she had talked to someone.The facility Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, indicated the policy was intended to protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse and to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect. Incidents to be reported included abuse and indicated suspected abuse shall be reported to the SA no later than two hours after forming the suspicion of abuse.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Robbinsdale

3130 Grimes Avenue North Robbinsdale, MN 55422

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

blood on the floor in the room. FM-A told FM-B Resident R1 had not responded when she called to her from the door.

When Resident R1 got up she was in so much pain, FM-A had asked the SW to call an ambulance. FM-B said Resident R1 had been and Resident R1 was found to have bruising on one whole side of her body, a broken hip, fractured ribs and a urinary tract infection.FM-B said Resident R1 had been at the facility for two days with a broken hip and was still in the hospital and had surgery to repair her hip. During interview on 11/20/25 at 12:04 p.m., nursing assistant (NA)-B stated she met Resident R1 when she transitioned to the third floor. NA-B said Resident R1 had been very independent and staff typically just checked on her. NA-B said before the two falls, Resident R1 walked but afterward had been staying in her wheelchair.During interview on 11/20/25 at 12:09 p.m., NA-A stated on Friday morning (11/14/25), she asked Resident R1 if she needed anything. NA-A said she attempted to change Resident R1 due to incontinence and Resident R1 did not want to put clothes on. NA-A said when she changed Resident R1's incontinent brief

she rolled a little to one side but could not roll onto the opposite side. NA-A said she did not recall if she saw any bruising.During interview on 11/20/25 at 12:47 p.m., the director of nursing (DON) stated Resident R1 had a past medical history of falls and fractures and said any little thing would probably fracture her. The DON said after a fall, staff should perform and assessment, completed neurological checks for 72 hours and if an obvious injury was noted, send the resident to the hospital. The DON said he had been told a neurological flow sheet had been completed but he had not seen it and did not know where it was. The DON said he had been told after Resident R1 went to the hospital she had a fracture.During interview on 11/20/25 at 1:53 p.m., the ACP-SW stated she had been onsite at the facility and was asked to see Resident R1. The ACP-SW said Resident R1 had presented as delusional. She said Resident R1 was in bed during the visit and had been pretty still and reported pain

in her leg which she had attributed to staff care. The ACP-SW said she reported the care concern and the report of pain to LSW-A.During interview on 11/13/25 at 2:01 p.m., the therapy director (TD) stated Resident R1 had been doing better and was using a walker prior to her falls. The TD said after the falls Resident R1 had not made much progress. The TD said she reviewed Resident R1's therapy notes and she had not been wanting to walk.

During interview on 11/20/25 at 2:40 p.m., LSW-A stated she had spoken to the ACP-SW after her session with Resident R1. LSW-A said she did not report the concern about pain to anyone because the ACP-SW said she had talked to someone.During interview on 11/20/25 at 2:44 p.m., the DON stated he expected staff to perform ongoing monitoring of vital signs, any pain and/or injury. The DON stated if bruising was present staff were to put an order in the medication administration record to monitor. A policy related to ongoing assessment after a fall was requested but not received.

Event ID:

Facility ID:

If continuation sheet