The Villas at Robbinsdale

Inspectors wroteBased on observation, interview and document review the facility failed to ensure they had an accurate accounting of controlled substances in 2 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the correct physician provider orders for life-sustaining treatment (POLST) were in the correct chart for 1 of 1 resident (R46) reviewed for resuscitation orders.

Inspectors wroteBased on interview and document review, the facility failed to ensure physician-ordered monitoring for potential adverse effects related to antipsychotic medication use was completed when orthostatic blood pressures (BP) were not obtained as ordered for 1 of 5 residents (R6) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure oxygen orders were followed as written for 1 of 1 resident (R48) reviewed for oxygen therapy.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure tobacco products were maintained in a secured, locked container when not in use for 1 of 1 residents (R53) reviewed for smoking safety.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 7.41% with 2 errors out of 27 opportunities for error involving 1 of 4 residents (R19) who were observed during the medication passes.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the medication refrigerators in 2 of 2 medication rooms were at the proper temperature for medication storage.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) prior to entering 1 of 1 resident's (R48) room who was in contact precautions.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R6, R46) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and document review, the facility failed to ensure the Ombudsman was notified of a facility transfer for 1 of 1 resident (R73).

Inspectors wroteBased on interview and document review the facility failed to provide supervision and care planned individualized interventions resulting in the risk for serious harm, injury impairment or death for 1 of 5 residents (R1) who was an elopement risk, was actively attempting to leave the facility, and succeeded with eloping on 3/7/26. R1 was located one hour and 20 minutes later, by the police, about 5 blocks from the facility. In addition, to R1 in immediate jeopardy, the facility failed to develop supervision and care planned individualized interventions with the potential for harm that is not immediate jeopardy for 3 of 3, residents (R3, R4, R5) reviewed for elopement risks. The immediate jeopardy began on 3/7/26 when the facility failure to provide adequate supervision resulted in R1's elopement and was identified on 3/13/26. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure the facility assessment included the required components of a plan for recruitment and retention of staff. This had the opportunity to affect all 71 residents.

Inspectors wroteBased on interview and document review the facility failed to ensure competency evaluation on the Minnesota Nursing Assistant Register for 1 of 1 nursing assistants (NA)-A) reviewed for registry verification. This had the potential to affect all 71 residents at the facility.

Inspectors wroteBased 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 (R1) reviewed for abusefindings includeR1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was independent with all activities of daily living. R1's undated admission Record identified R1 admitted to the facility on [DATE]. Diagnosis included fracture of vertebrae, diabetes, depression and hypertension. R1's care plan dated 11/14/25, identified an alteration in mobility and staff were to assist with transfers and bed mobility. 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. R1 expressed concern for how a staff person moved her around the previous day and spoke of people being in her bed with her. [...]

Inspectors wroteBased on interview and document review the facility failed to provide evidence of ongoing clinical assessments following a fall for 1 of 3 residents (R1) reviewed for falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure soiled facility linens were handled in a manner that prevented potential contamination during the laundry process. This deficient practice had the potential to affect all 65 residents served by the facility laundry.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 2 of 2 residents (R 11, and R35) who resided on the second floor reviewed for food. This deficient practice had the potential to affect all 24 residents residing on this unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items in community refrigerators were properly labeled and dated in 2 of 3 refrigerators where resident's personal food was stored. In addition, the facility failed to ensure food temperatures were maintained according to acceptable standards on 1 of 3 steam tables, and failed to maintain sanitary conditions during food prep. REFRIGERATORS During an observation on 4/28/25 at 12:52 p.m., the fourth floor refrigerator contained an undated and unlabeled plastic bag, 1/2 plastic pitcher with orange liquid, with no date, and a container of ice cream dated 3/4. The bag contained a Tupperware container. Dietary Manager (DM) verified the containers were for resident consumption and should have been dated. DM stated the juice should have been dated when it was placed in the refrigerator. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to follow standards of practice related to medication administration of an inhalation medication for 1 of 3 residents (R26) observed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions implemented for 1 of 3 (R41) residents identified at risk for falls.

Inspectors wroteBased on interview and document review, the facility failed to implement a system to ensure medications were available to administer as ordered for 1 of 1 residents (R7) reviewed for medication administration. Findings Include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 was cognitively intact and had diagnoses which included: asthma, chronic obstructive pulmonary disorder (COPD) (breathing difficulty) and diabetes mellitus. R7 was dependent on staff for dressing and toileting. R7's care plan dated 4/17/25, identified R7 was at risk for decreased cognation and physical abilities related to diagnosis of COPD and asthma. Review of physician orders placed on 4/17/25, revealed the following order placed: Anoro Ellipta (medication used for COPD) 62.5-25 micrograms (mcg) aerosol powder on puff daily. Review of R7's eMAR dated 4/25, revealed the following: [...]

Inspectors wroteBased on interview and document review, the facility failed to update the provider of a medication refusal of Lovenox (medication used to prevent blood clots following surgery) for 1 of 3 residents (R2) reviewed for medication administration.

Inspectors wroteBased on interview, observation, and document review the facility failed to provide wound care as ordered for 1 of 3 residents (R2) reviewed for wound care. Additionally, the facility failed to ensure R2's care plan indicated wound care and pouch changes for the fistula.

Inspectors wroteBased on interview, observation, and document review the facility failed to conduct appropriate hand hygiene during wound care for 1 of 3 residents (R2) reviewed for wound care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 1 residents (R1) reviewed for skin alterations had weekly skin observations completed, in addition to informing the interdisciplinary team of R1's skin breakdown.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 3 ice dispensing machines were clean and free of excess mineral build up and cleaned on a regular schedule. This had potential to affect all residents of the nursing home, staff, and visitors who consumed food from the main production kitchen and/or ice and water from the fourth floor dining room ice machine.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure timely assistance with incontinence care when requested to promote dignity for 1 of 1 residents (R41) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively re-assess for ability or safety, document resident education regarding risks, and care plan the self-administration of medications for 1 of 1 resident (R41) known to obtain their own medication from outside sources, who was observed to have such medications at bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and monitor non-pressure related skin conditions for 1 of 2 residents (R40) reviewed for skin concerns, and failed to monitor resident weights for 1 of 1 residents (R40) reviewed who took a diuretic and had a history of weight fluctuations.

Inspectors wroteBased on observation, interviews and document review, the facility failed to ensure that residents received proper follow-up recommendation for hearing assistive devices to maintain hearing abilities for 1 of 1 residents (R12) reviewed for hearing services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure refrigerated food items were disposed of after expiration date and were properly stored, labeled, and dated when the original packaging was opened. This deficient practice had the potential to affect all 70 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food a residents brought in from the outside was dated and labeled the transitional care unit. This had the potential to affect all 20 residents who resided on that floor. In addition, the facility was unable to provide documentation that the residents communal refrigerator temperatures were being monitored.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide personal hygiene to 3 of 4 residents (R2, R6, and R7) dependent on staff for activities of daily living (ADL's). The residents did not receive timely showers or weekly skin assessments.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 4 residents (R6 and R7) received daily weights as ordered to monitor for heart failure and unexplained weight loss.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain a medical record that was accurately documented for 1 of 1 resident (R1), when Registered Nurse (RN)-A documented a completed treatment that had not been completed.

Inspectors wrotePolicy titled Infection Prevention and Control- Contact Precautions dated 7/31/23 identifies contact precautions are intended to prevent transmission of the infectious agents, including epidemiologically important microorganisms, spread by direct or indirect contact with the resident or the residents environment. In addition to Standard Precautions, Contact Precautions will be used to prevent the healthcare acquired spread of organisms that can be transmitted by direct or indirect resident contact (hand or skin-toskin contact that occurs when performing resident care) or by indirect contact (touching) with environmental surfaces of contained resident care equipment. Contact Precautions may be considered for residents who have: 1. Infections (including Multi-Drug Resistant Organisms (MDROs)) 3. Uncontained wound drainage from an infected wound 5. [...]