The Villas at New Brighton

Inspectors wroteBased on interview and document review, the facility failed to ensure steroid medication was given in accordance with physician orders for 1 of 3 residents (R1) reviewed. R1 had a history of long-term steroid use and multiple complex medical conditions. R1 had orders from the hospital for prednisone (a steroid medication) which were not correctly transcribed into the care center record (EMR) causing at least one missed dose. This error contributed to R1 developing an adrenal crisis and being hospitalized which constitutes actual harm. However, the facility took corrective actions on 7/24/26 prior to the onsite investigation, so these

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of potential neglect of healthcare was reported to the State agency (SA) for 1 of 1 resident (R1) reviewed who had a significant medication error resulting in an adrenal crisis and hospitalization.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were labeled with current and accurate administration instructions to reduce the risk of medication error for 1 of 1 resident (R2) whose medication administration was observed.

Inspectors wroteBased on observation and interview, the facility failed to properly store and label medications for 1 of 3 residents (R3) reviewed and for medications in medication cart 1 located on the respiratory care unit (RCU) . This had the opportunity to affect all ten residents whose medications were stored in the cart.

Inspectors wroteBased on interview and document review the facility failed to include clinical indications for medication and treatments prescribed for 2 of 4 (R2,R3) residents reviewed for standards of practice.

Inspectors wroteBased on observation and interviews, the facility failed to verify placement of a gastric tube (g-tube) prior to medication administration for 1 of 2 residents (R3) reviewed for medication administration via feeding tube.

Inspectors wroteBased on interview and document review the facility failed to coordinate care with the dialysis center for 1 of 2 residents (R4) reviewed for dialysis. This had the opportunity to affect two of the residents at the facility.

Inspectors wroteBased on observation and interviews, the facility failed to maintain clean technique with the gastric feeding tubing for 1 of 2 residents (R3) reviewed for medication administration via enteral feeding.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll during 1 of 1 quarter (Quarter 1) reviewed, to the Centers for Medicare Services (CMS), according to specification established by CMS. This had the potential to affect all 83 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's walk-in freezer was maintained to ensure water drippings and ice build-up would impact frozen food storage. This had the potential to impact all residents who ate from the kitchen. During an observation of the kitchen on 4/22/26 at 9:21 a.m., the walk-in freezer was observed. Inside the freezer, the ceiling had numerous frozen water drops out into the middle of the walk-in freezer, across from the two fans on the left side of the walk-in freezer. On the floor of the walk-in freezer were three frozen areas approximately 12 inches in diameter. An interview on 4/22/26 at 9:22 am., the culinary director (CD) stated the the walk-in freezer had been like that for a couple of weeks. The CD stated the regional person came out and de iced the walk-in freezer. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure safe storage of medication on 4 of 6 medications carts reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident rights were maintained for 1 of 2 residents (R71) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to honor a resident's right to make choices about aspects of care for 1 of 2 residents (R71) reviewed for self-determination.

Inspectors wroteBased on interview and document review, the facility failed to notify a resident/resident representative Medicare part A coverage would end prior to going on a leave of absence (LOA) for one of one residents (R11) reviewed for therapy services.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities of daily living (ADLs) for 2 of 2 resident (R62 and R71) who were dependent on staff for assistance with ADLs.

Inspectors wroteBased on interview and document review, the facility failed follow up on pharmacist recommendations for 1 of 5 residents (R23) reviewed for monthly pharmacist reviews.

Inspectors wroteBased on interviews and document reviews, the facility failed to ensure care was delivered in accordance with professional standards and care planning for 1 of 3 residents (R1) reviewed for quality of care. R1 had severe cognitive impairment and frequently crawled out of bed to the floor. This resulted in Psychosocial harm for R1 when staff would drag R1 from the floor to the bed for repositioning without the care planned use of a mechanical lift. A reasonable person concept is applied in determining what the psychosocial outcome would have on a reasonable person in a similar situation to suffer because of the noncompliance. Findings Include: Observation of R1's room on 3/19/26 at 2:40 p.m., was a shared room, where her space was closest to the door with a privacy curtain between her side and her roommate's side. R1's bed was against the wall, lengthwise. [...]

Inspectors wroteBased on interview and record review the facility failed to provide an opportunity for 1 of 3 residents (R1) reviewed for care planning to participate in the development of the plan of care. Findings Include: During an observation on 3/20/26, at 8:30 a.m., R1 was seated at the edge of the floor mattress. Her breakfast tray was positioned to her left side on the floor mattress. R1 was leaning on her left elbow as she reached with a fork, using her right hand to eat the food from her tray. Food was observed falling on to the mattress as she tried to eat. R1's admission Minimum Data Set (MDS), dated [DATE], indicated she had diagnoses of heart failure and respiratory failure, she had severe cognitive impairment, was Hmong speaking, and was dependent for all cares and transfers. R1's care plan, dated 2/18/26, indicated she was a fall risk and had a fall mat at her bedside. [...]

Inspectors wroteBased on interview and record review the facility failed to follow established infection control practices for 1 of 3 residents (R1) reviewed for hand hygiene when staff failed to perform hand hygiene. Findings Include: During an observation on 3/19/26, at 2:40 p.m., nursing assistant (NA)-C and NA-D performed incontinence cares for R1 in her bed. NA-D assisted with positioning of R1 in her bed as NA-C removed the soiled brief, wiped R1's perineum and buttocks, then discarded the brief and wipes. She failed to remove her gloves and perform hand hygiene. [...]

Inspectors wroteBased on interview, observation, and document review, the facility failed to develop care plans for 2 of 3 residents (R2, R3) reviewed for baths/ showers. R2 and R3 refused baths/showers and their care plans did not include interventions for refusals.

Inspectors wroteBased on interview and document review, the facility failed to ensure safe transfers with a full body mechanical lift. This resulted in an immediate jeopardy (IJ) for 1 of 4 residents (R1) who sustained a left femur fracture due to a fall from a lift. The immediate jeopardy (IJ) began on 8/29/25, when R1 fell out of a full mechanical lift sling that was not attached to the lift according to manufacturer instructions resulting in a fall with fracture for R1. The administrator and director of nursing (DON) were notified of the IJ on 9/10/25 at 1:49 p.m. The IJ was removed on 9/2/25, prior to the start of the survey, when the facility implemented immediate corrective action to prevent recurrence, therefore, the IJ was issued at past non-compliance.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 resident (R4) observed with medications at their bedside.

Inspectors wroteBased 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 (R1) reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dignified living existence for 3 of 3 residents (R1, R2, and R3) reviewed. Staff failed to respond timely to the residents, leaving them incontinent of stool in their beds while waiting on staff assistance.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll during 1 of 1 quarter (Quarter 2) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 78 residents at the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure voiced grievances and complaints against the facility were acted upon, investigated or resolved for 1 of 1 resident (R1) reviewed who had grievances.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care, treatment, and services to prevent pressure ulcer development for 1 of 3 residents (R1). This resulted in an immediate jeopardy (IJ) who presented to the emergency room (ER) on 4/3/25 with multiple pressure ulcers and wound infections. R1 remained hospitalized . The IJ began on 4/3/25, when the facility failed to assess, report to the provider, and treat pressure ulcers. R1 was found unresponsive and presented to the hospital emergency room on 4/3/25, and it was discovered she had multiple pressure ulcers and wound infections. R1 remained hospitalized . The facility administrator and director of nursing (DON) were notified of the IJ at 4:00 p.m. on 4/15/25. The facility implemented corrective action by 4/9/25, prior to the start of the survey and was issued as past non-compliance. [...]

Inspectors wroteBased on interview and record review the facility failed to comprehensively assess and monitor a resident's g-tube site and provide interventions for skin irritations for 1 of 1 resident (R1) reviewed for non-pressure related skin concerns.

Inspectors wroteBased on interview and document review, the facility failed to ensure licensed nurses demonstrated and/or acknowledged required competency skills for completion of weekly skin assessments for 1 of 3 residents (R1) identified to have worsening skin conditions. This had the potential to affect all 83 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure appropriate personal protective equipment (PPE) practices were performed during a high contact care activity for 1 of 2 residents (R3) in enhanced barrier precautions (EBP) with an indwelling device.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement a process to supervise and monitor R3, who is known to smoke with oxygen on, to ensure he left the oxygen in the facility while he was smoking in the designated smoking patio resulting in risk of injury, burns, or fire which had the potential to cause serious harm, injury, impairment, or death to 1 out of 16 residents (R3) reviewed who smoked. The immediate jeopardy began on 4/4/25 when the failure to monitor and supervise R3's smoking, and was identified on 4/4/25. The administrator, director of nursing, and regional nurse consultant were notified of the immediate jeopardy at 4:10 p.m. on 4/4/25. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a system was in place to prevent the diversion of medications for 30 of 79 residents (R1, R5, R12, R15, R16, R27, R35, R41, R49, R50, R54, R58, R63, R73, R75, R76, R77, R141, R146, R149, R345, R25, R143, R144, R145, R147, R148, R150, and R151) reviewed for drug diversion and were free from misappropriation of their property when their medications to treat moderate to severe pain and other conditions were taken by a staff member. This resulted in diversion of 111 tablets of oxycodone 5 milligram (mg), 21 tablets of oxycodone 2.5 mg, 28 tablets of oxycodone 10 mg, 1 tablet Aderall, 6 tablets Percocet, and 4 tablets Ambien which resulted in the likelihood of serious harm or adverse event to residents prescribed controlled substances. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement a system to secure stored narcotics for 1 of 9 residents (R35) reviewed for diversion. Further, the facility failed to ensure medications were properly labeled with name and directions for use and stored in a manner that addressed infection control concerns in 6 of 6 medication cart reviewed for medication storage. This had the potential to affect all 20 residents who used insulin.

Inspectors wroteBased on observation and document review, the facility failed to ensure the required nurse staffing information was posted daily for 3 of 6 days reviewed. This had the potential to affect all 57 residents residing in the facility and their visitors who may wish to view the information.

Inspectors wroteBased on observation, interview and document review the facility failed ensure a resident was allowed to dress in a manner of her choosing for 1 of 1 residents (R59) reviewed for dignity. Findings Include: R59's quarterly Minimum Data Set (MDS) dated [DATE], indicated R59 was severely cognitively impaired and required moderate assistance with dressing her upper body and was dependent with dressing her lower body. R59 had a diagnosis of hemiplegia (inability to move one side of her body) following a cerebral infarction (stroke) on her right dominate side. On 2/3/25 at 5:40 p.m., R59 was observed next to the nurse's station in a wheelchair with legs elevated and covered with a blanket, dressed in a hospital gown. R59's hair was brushed. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to properly assess 1 of 1 residents (R39) who wished to self-administer medications.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation of sexual abuse to the state agency and law enforcement for 1 of 2 residents (R57) reviewed for abuse. In addition, the facility failed to immediately protect R57 from further abuse.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 1 residents (R57) who reported an alleged sexual assault.

Inspectors wroteBased on interview and document review, the facility failed to develop and implement a comprehensive person-centered care plan that addressed resident dialysis care for 1 of 1 residents (R72). Further, the facility failed to address clothing preference and passive range of motion (PROM) for 1 of 1 resident's (R59) reviewed for care plan.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered according to provider order and within professional standards for 1 of 1 residents (R2) observed during medication passes with parameters.

Inspectors wroteBased on observation, interview and document review the facility failed ensure a resident received range of motion exercises for 1 of 1 residents (R59) reviewed for passive range of motion. Findings Include: R59's quarterly Minimum Data Set (MDS) dated [DATE], indicated R59 was severely cognitively impaired, required moderate assistance with dressing upper body and was dependent with dressing lower body. R59 had functional limitations in range of motion to her upper and lower extremity on one side. R59 had a diagnosis of hemiplegia (inability to move one side of her body) following a cerebral infarction (CVA) (stroke) on her right dominate side. On 2/3/25 at 5:40 p.m., R59 was observed next to the nurse's station in a wheelchair with legs elevated and covered with a blanket, dressed in a hospital gown. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assessment and monitoring for 1 of 1 residents (R72) reviewed for dialysis.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure they were free of medication error rate of five percent or greater. The facility had a mediation error rate of 8% with 2 errors out of 25 opportunities for errors involving 2 of 6 residents (R2, R240) observed during medication passes.

Inspectors wroteBased on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 6 medication carts and one instance of medications left unattended in a resident room.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct appropriate hand hygiene during tracheostomy cares for 1 of 1 resident (R8) observed for tracheostomy cares. Further, the facility failed to ensure proper catheter drainage bag care and catheter drainage bag laying on the floor for 1 of 1 resident (R12) observed for cares.

Inspectors wroteBased on interview and document review, the facility failed to ensure professional standards of practice for medication administration were followed for 1 of 3 residents (R1) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure a referral was made to an outside agency for psychiatric services as ordered by a physician for 1 of 1 resident (R3) reviewed.

Inspectors wroteBased on interview and record review, the facility failed to notify resident's family of changes in condition for one of one resident (R2) reviewed. R2 had a left toe ulcer that developed on [DATE] and R1's power of attorney was not notified until R1 had to have the toe amputated on [DATE].

Inspectors wroteBased on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respirations, no CPR was initiated, and R1 experienced certain death. The facility implemented corrective action, so the deficient practice was issued at past non-compliance. The IJ began on [DATE], when R1 was found unresponsive with an absence of pulse and respirations, CPR was not initiated, and R1 experienced certain death. [...]

Inspectors wroteBased on interview and document review, the facility failed to implement policies and procedures for the use of methadone hydrochloride (HCI, a synthetic medication used to treat addiction) treatment for acquisition, administration, destruction, and an appropriate taper for 1 of 1 resident (R2) reviewed for medication administration. Additionally, the facility failed to implement policies and procedures to ensure rapid detection of potential narcotic diversion for 6 of 6 medication carts reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement appropriate personal protective equipment per Centers for Disease Control and Prevention (CDC) to prevent and/or minimize spread of COVID-19 for 2 of 2 residents (R5, R15) observed for COVID-19 transmission based precaution (TBP). This deficient practice had the potential to affect all 82 residents who were currently residing in the facility. Findings Include: [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess residents for the ability to self administer medications (SAM) for 2 of 2 residents (R42, R79) with medications noted at bedside. R42's admission MDS dated [DATE], identified intact cognition and diagnoses of type two diabetes with kidney complications, depression, and cataracts, glaucoma, or macular degeneration. R42 required partial to moderate assistance with eating. R42's care plan dated 12/18/23, lacked a focus area for SAM. R42's order summary and assessments dated 1/8/24, lacked direction related to SAM. During an observation and interview on 1/8/24 at 3:45 p.m., R42 was in bed. There was a half-full 8 ounce bottle of Pepto-Bismol on his bedside table, without a pharmacy label. R42 stated he could take the Pepto-Bismol any time he wanted to, and usually took a swig a few times per day for nausea. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a clean and comfortable environment as well as failed to ensure a tube feeding pole and tracheostomy supplies cart was cleaned and in sanitary condition for 1 of 1 residents (R54) reviewed for homelike environment.

Inspectors wroteBased on observation, interview and record review the facility failed to revise the comprehensive care plan for 1 of 5 residents (R23), reviewed for activities of daily living (ADL). In addition, the facility failed to ensure residents/resident representatives were allowed to participate in care planning for 2 of 5 (R23, R67 ) reviewed for ADLs.

Inspectors wroteBased on observation, interview and document review the facility failed to provide the services to maintain dressing and personal hygiene needs for 1 of 5 residents (R23) observed for activities of daily living (ADL's).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide fingernail care to a dependent resident for 1 of 1 resident (R54) reviewed for dependent activities of daily living (ADL) care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure pain management was provided in accordance with professional standards of practice for 1 of 1 resident (R21) reviewed for pain during wound care.

Inspectors wroteBased on interview, and document review, the facility failed to ensure post-dialysis access site monitoring was completed and documented for 1 of 1 resident (R41) reviewed for dialysis.

Inspectors wroteBased on interview and document review the facility failed to provide medically related social services for 1 of 1 resident (R23) who lacked sufficient clothing. Findings Include: R23's admission Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnoses which included: schizophrenia, chronic obstructive pulmonary disease (COPD) and respiratory failure. R23's MDS also identified R23 required supervision or touching assistance for upper and lower body dressing and set up assistance for personal hygiene. R23's Care Area Assessment (CAA) dated 12/6/23, identified R23 had some cognition issues, planned to return to her apartment where R23 lived alone, and was at risk for isolation, depression, and further cognitive decline. [...]

Inspectors wroteBased on interview and document review, the facility failed to have a method or system to ensure the facility offered or provided updated pneumococcal vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations for 1 of 5 residents (R49) reviewed for immunizations. This had the ability to affect all 82 residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure complaints of worsening right arm pain following a fall was comprehensively assessed and treated in a timely manner to provide comfort for 1 of 3 residents (R1) reviewed for falls. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, and had a diagnosis of heart failure. R1's Physician Orders dated 10/30/23 directed acetaminophen (Tylenol, a pain reliever) 1000 milligrams (mg) three times a day. R1 did not have an order to receive acetaminophen on a PRN (as needed) basis. R1's medication administration record (MAR) for 11/23 indicated she received acetaminophen four scheduled times following the fall. R1 rated her pain as on 11/7/23 as 5 out of 10 (0 being no pain to 10 being the worst pain) for the morning dose, 6 out of 10 mid-day dose, 7 out of 10 evening dose. [...]