Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New Brighton Care Center during CMS and state inspections, most recent first.
Facility failed to develop and document a facility assessment that included plans for staff recruitment and retention. The assessment included staffing records, a general staffing plan, staff assignments, and staff training and competencies, but it did not address recruitment or retention of direct care staff. The administrator confirmed the omission during interview, and the issue had the potential to affect all 43 residents.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data to CMS for a quarter, with the report showing no RN hours, no 24-hour licensed nursing coverage on multiple days, and excessively low weekend staffing. Although schedules reviewed showed RN coverage, 24-hour licensed nursing coverage, and weekend staffing equal to weekdays, staff stated the quarter 3 PBJ submission may have omitted agency hours and the facility policy for PBJ reporting was not provided.
The facility failed to provide ongoing communication about resident rights during resident council meetings for two cognitively intact residents. Meeting minutes did not include resident rights, and both residents stated rights were not discussed in council meetings or remembered from admission. The AD confirmed rights were not routinely reviewed during the meetings, and the resident council policy did not address reviewing resident rights.
Improper glove use and hand hygiene during meal prep. A cook repeatedly left and re-entered the kitchen, handled door knobs, kitchen equipment, and dirty cooking sheets, and then returned to food prep without washing hands or changing gloves. He also used oven mitts over gloved hands to check food in the oven and later plated food for resident trays with the same gloves. The ADM and dietary manager stated gloves should be changed between dirty and clean tasks, and the cook confirmed he did not follow that practice.
An RN and the DON entered a resident’s room under EBP without gowns or gloves and repositioned the resident before tube feeding medication administration, despite the resident having a G tube and EBP signage posted. In a separate event, an LPN used a shared glucometer for a resident with diabetes, did not disinfect it immediately after use, and then cleaned it for only about 10 seconds instead of the label-specified 2-minute contact time.
A resident with multiple medical conditions reported that a nursing assistant was rough and rude during care, resulting in pain and psychological distress. Despite facility policy requiring prompt reporting of abuse allegations to the State agency, staff did not report the incident, citing the resident's history and lack of injury. The investigation documentation was incomplete, and the event was handled as a grievance rather than a reportable abuse allegation.
A resident with multiple health conditions reported that a nursing assistant was rough and rude during dressing care, resulting in pain and emotional distress. The facility did not complete required documentation, failed to conduct a thorough investigation as per policy, and did not perform or document necessary assessments or interviews related to the incident.
The facility failed to post required daily nurse staffing information, affecting all 41 residents and their visitors. The staffing coordinator did not complete postings on weekends, unaware of the daily requirement. The administrator expected daily postings, with responsibilities divided between the staffing coordinator and the north nurse. The facility's policy required posting staffing numbers per CMS guidelines.
The facility did not submit staffing data to CMS for the third quarter of 2024, as required. The human resources specialist responsible for this task forgot to complete the submission, leading to suppressed metrics for weekend staffing and nursing coverage. The facility's policy lacked specific submission guidelines.
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, potentially affecting all 41 residents. The interim DON and ADON shared IP duties but had not completed the required training. A policy related to the specialized training was requested but not provided.
The facility failed to label insulin flexpens and eye drops with an 'opened on' date and did not secure controlled substances properly. Medications in three carts were not labeled, and an emergency kit with controlled substances was not locked as required. The DON confirmed the expectation for labeling and discarding multi-dose vials, but policies were not followed, posing risks to all residents.
The facility failed to provide the required SNFABN-CMS-10055 to two residents, resulting in a deficiency. One resident was discharged without receiving the notice, and another entered hospice care without it. The director of social services and the administrator acknowledged the oversight, and the facility's policy was not followed.
A facility failed to provide written notification of hospital transfers to a resident and their representative, as well as to the LTC Ombudsman, for a resident with multiple hospitalizations. Despite the resident's cognitive intactness and medical conditions, records lacked documentation of notifications for these transfers. Interviews confirmed that the required notifications were not completed, contrary to the facility's policy.
A facility failed to provide required bed hold notices during multiple hospital transfers for a resident with various medical conditions, including diabetes and COPD. Despite the facility's policy requiring written notice at the time of transfer, the resident's records lacked evidence of such notices. Interviews confirmed the oversight, highlighting a pattern of non-compliance with the facility's procedures.
A resident with a history of diabetes, stroke, and COPD experienced adverse skin reactions due to the continued application of ammonium lactate cream, despite a wound clinic's directive to discontinue its use. The facility failed to update the treatment plan, resulting in the cream being applied twice after the directive. The resident's condition included swollen, blistered lower extremities, and the DON confirmed the oversight.
A resident with a stage 4 pressure ulcer did not receive proper infection control during wound care. Two LPNs failed to remove a soiled chux pad and left a fan blowing directly at the exposed wound. They did not ask the resident for permission to turn off the fan, nor did they date or initial the new dressing. The DON expected soiled pads to be removed, dressings to be dated and initialed, and fans to be turned off during dressing changes.
The facility failed to offer the PCV20 vaccine to two residents with chronic conditions, despite CDC recommendations and facility policy. The residents had received previous pneumococcal vaccines but lacked shared clinical decision-making for the PCV20. The DON/IP confirmed the oversight and the importance of offering the vaccine to maintain resident health.
Facility Assessment Missing Recruitment and Retention Plan
Penalty
Summary
The facility failed to develop and document a facility-wide assessment that included plans for the recruitment and retention of staff. The assessment dated [DATE] included sections on how to obtain staffing records, a general staffing plan, staff assignments, and staff training and competencies, but it did not include a section on staff recruitment and retention. During interview on 11/18/25 at 4:20 p.m., the administrator confirmed that the facility assessment did not include information on the facility's plan to maximize recruitment and retention of direct care staff. This deficiency had the potential to affect all 43 residents.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for quarter 3. Review of the PBJ report for April 1 through June 30, 2025 identified excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours a day. The report also triggered a one-star staffing rating. Dates identified for no RN coverage included 5/4/25, 5/31/25, 6/15/25, 6/22/25, 6/28/25, and 6/29/25. Dates identified for not having 24-hour licensed nursing coverage included 5/3/25, 5/4/25, 5/18/25, 5/31/25, 6/1/25, 6/15/25, 6/28/25, and 6/29/25. Review of schedules for the same period showed RN coverage for all dates, 24-hour licensed nursing coverage for all dates, and staffing equal to weekdays for weekend coverage. During interview, HR-A stated she submitted PBJ data quarterly and included hours for exempt and non-exempt staff, including agency and contracted staff, but did not submit the quarter 3 data because she started after that date. The administrator stated a sister agency submitted the quarter 3 PBJ data and believed agency hours may not have been calculated and submitted. Facility policy for PBJ reporting was requested but not provided.
Failure to Review Resident Rights in Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents about their rights during resident council meetings for 2 cognitively intact residents, R12 and R28, who could understand others and make themselves understood. Review of resident council meeting minutes for July 2025 through October 2025 did not include information on resident rights. During a resident council meeting interview, R12 and R28 stated they did not discuss resident rights in the meetings and did not remember going over resident rights during admission. They also stated they were not aware resident rights were posted on a bulletin board in the building. The activities director, who organized and ran the resident council meetings, confirmed that resident rights were not reviewed as part of the meetings, although she would answer questions if a resident specifically brought them up. The facility’s resident council policy dated February 2011 did not include information on reviewing resident rights.
Improper glove use and hand hygiene during meal preparation
Penalty
Summary
Food was not prepared and distributed under sanitary conditions during observation of the midday meal on 11/19/25. A cook was observed wearing disposable gloves while setting up trays, then repeatedly leaving and re-entering the kitchen, touching the door handle and door knob, handling kitchen equipment, and carrying dirty cooking sheets while keeping the same gloves on. After each of these actions, the cook did not wash his hands or change his gloves before returning to food preparation tasks. The cook also used oven mitts over his gloved hands to check breadsticks and later a lasagna in the oven, then removed the mitts and wrote down the lasagna temperature with the same gloves still on. At 11:50 a.m., the cook began serving food onto resident trays and plated bread sticks by picking them up with a gloved hand. The administrator stated gloves should have been changed every time kitchen staff entered the kitchen or went from a dirty to clean task, and hands should have been washed when gloves were changed. The dietary manager stated staff complete infection control training when hired and yearly, but she had not completed an extended audit of meal prep to ensure proper hand hygiene was being completed. The cook confirmed he did not wash his hands or change gloves each time he exited and reentered the kitchen and stated staff were taught to wash hands and change gloves when moving from dirty to clean tasks and any time entering the kitchen.
Failure to Use Proper PPE and Disinfect Shared Glucometer
Penalty
Summary
The facility failed to ensure proper PPE was used when providing care to a resident on enhanced barrier precautions (EBP). The resident had a gastrostomy tube and was identified in the care plan as being on EBP. During observation, an RN and the DON entered the resident’s room after preparing medications for tube feeding administration without donning gowns or gloves. They boosted the resident higher in bed by grasping the draw sheet and repositioning him while in contact with the bedding and resident. The RN then administered tube feeding medications while wearing gloves. The RN later confirmed she was not wearing a gown during the medication administration, and the DON confirmed proper PPE was not worn during repositioning or tube feeding medication administration. The facility policy stated EBP was intended to prevent transfer of MDROs to employees’ hands or clothing during care and required PPE during care involving a feeding tube or transfers. The facility also failed to properly disinfect a shared glucometer between uses. A resident with diabetes had an order for blood glucose monitoring four times per day. During observation, an LPN completed a blood sugar check using the shared glucometer and the resident brought the device out of the room and placed it on the medication cart. The LPN did not clean the glucometer immediately after use. About 13 minutes later, the LPN retrieved a disinfecting wipe and cleaned the glucometer by wiping both sides for approximately 10 seconds, then discarded the wipe. The LPN stated he was unsure of the required contact time and confirmed he did not clean it for the 2 minutes specified on the label. The DON confirmed the glucometer should be cleaned with the purple-top disinfecting wipe according to label directions and stated it should be wiped immediately after use before being put away. The facility policy for disinfecting blood glucose monitors required multiple wipe passes and a 2-minute wrap with a disinfecting towelette before the next use.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving a cognitively intact resident was reported in a timely manner to the State agency (SA). The resident, who had diagnoses including bipolar disorder, anxiety, depression, morbid obesity, chronic pain, and arthritis, required significant assistance with dressing and bed mobility. The resident reported to the social worker that a nursing assistant was 'rough' and 'rude' during dressing care, resulting in shoulder pain and a request for an x-ray. The incident was documented as a grievance, but key sections of the investigation form, including the summary of investigation, corrective actions, and required signatures, were left blank. Multiple staff interviews revealed that the allegation was not reported to the SA because facility leadership did not believe the incident rose to the level of abuse, citing the resident's history of frequent grievances and the absence of physical injury. Despite this, the resident described the care as aggressive and abusive, reporting both physical pain and psychological distress, including nightmares. The nursing assistant involved was placed on a 'do not return' list, but the incident was not escalated as required by facility policy and regulatory guidelines. Facility policy required all reports of abuse, neglect, or exploitation to be reported to local, state, and federal agencies, with immediate notification to the administrator. Staff interviews confirmed an expectation to report such allegations within two hours if serious bodily injury was involved, or within 24 hours otherwise. However, the facility did not follow these protocols, as the allegation was treated as a grievance rather than a reportable abuse incident, and the investigation was not completed or reported in the required timeframe.
Failure to Thoroughly Investigate Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse reported by a cognitively intact resident with multiple diagnoses, including bipolar disorder, anxiety, depression, morbid obesity, chronic pain, and arthritis. The resident required varying levels of assistance with activities of daily living and reported that a nursing assistant was rough and rude during dressing care, resulting in shoulder pain and emotional distress. The resident's care plan identified her as a vulnerable adult and directed that any suspicions of abuse or neglect be investigated. Upon review, the facility's documentation was incomplete. The grievance form related to the incident was not fully filled out, with key sections such as the summary of investigation, conclusion, corrective actions, and required signatures left blank. There was no evidence in the medical record that a nursing or body/skin assessment was conducted after the allegation, nor was there documentation of monitoring the resident for issues related to the incident. Interviews with facility staff revealed that only a limited number of interviews were conducted, and there was a lack of documentation for these interviews. No additional staff or residents were interviewed to determine if there were broader concerns regarding the care provided by the accused nursing assistant. The facility's own policies required a thorough investigation of all allegations, including reviewing documentation, interviewing all relevant parties, and documenting the investigation completely. However, the investigation was not completed as required, and there was no evidence that staff were educated regarding the concerns raised by the allegation. The failure to follow established protocols and to document the investigation process resulted in a lack of thoroughness in addressing the resident's report of rough care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the required staffing information was posted daily, which had the potential to affect all 41 residents and their visitors who may wish to review the information. During a review of staff posting documentation from April, May, June, and August 14th through October 14th, the facility could not provide evidence of staff postings for several specific dates across these months. On October 16th, the staffing coordinator confirmed that they had not been completing the staff posting on weekends and was unaware of the daily posting requirement. The administrator expected the staff posting to be displayed every day, with the staffing coordinator responsible during the week and the north nurse responsible on weekends. However, the administrator was unaware that the postings had not been completed on weekends. The facility's policy, dated December 12, 2022, indicated that it was their policy to post staffing numbers per Centers for Medicare and Medicaid guidelines.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to submit direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2024. This deficiency was identified through an interview and document review, which revealed that no data had been submitted for the specified period. The Payroll Based Journal Report for quarter 3, 2024, showed a lack of submission, resulting in the suppression of metrics for excessively low weekend staffing, Registered Nurse (RN) hours, and licensed nursing coverage. The human resources specialist responsible for the submission admitted to forgetting the final step in the process, acknowledging the importance of this task for the facility's star rating and public information. The facility's policy on staffing did not include specific submission requirements.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, which had the potential to affect all 41 residents residing in the facility. During an interview on October 17, 2024, the interim director of nursing (DON) stated that both the DON and the assistant director of nursing (ADON) shared the IP duties. However, neither the DON nor the ADON had completed the required specialized training in infection prevention and control. Additionally, when requested, the facility could not provide a policy related to the specialized training for the infection preventionist.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically insulin flexpens and eye drops, which were not labeled with an 'opened on' date. This oversight was observed in three medication carts, where medications such as Dorzolamide-timolol eye drops and Ozempic insulin flexpens were found without the required labeling. Additionally, the facility did not secure controlled substances properly, as evidenced by an emergency kit containing controlled substances that was not stored in a separately locked, permanently affixed compartment. This was noted in one of the medication carts and a medication refrigerator, which contained unlocked bottles of liquid Ativan. The Director of Nursing (DON) confirmed that licensed staff were expected to label multi-dose vials with the date they were opened and to discard them within 28 days unless otherwise specified by the manufacturer. However, the facility's policies on medication labeling and controlled substances were not adhered to, as controlled substances were found unlocked in a medication refrigerator. The manufacturer's directions for Ozempic and other medications were not followed, leading to potential risks for all residents in the facility.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) to two residents, R194 and R195, as required. R194 was admitted and later discharged from the facility, but the medical record lacked evidence that the SNFABN-CMS-10055 was provided, even though the discharge from Medicare Part A was initiated before benefit days were exhausted. Similarly, R195, who was admitted under the Medicare A benefit and later entered hospice care, did not receive the SNFABN-CMS-10055, as confirmed by the facility's records. Interviews with the director of social services and the administrator revealed that the facility was aware of the deficiency in providing the SNFABN-CMS-10055. The director of social services acknowledged the importance of these notices for residents to plan for discharge or appeal decisions. The administrator confirmed that a process to ensure the provision of these notices was not yet in place, despite being aware of the issue. The facility's policy indicated that residents should be notified in writing if Medicare would not cover certain services, but this was not adhered to in these cases.
Failure to Notify Resident and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to a resident and their representative, as well as to the Ombudsman for Long Term Care (LTC), for a resident who was transferred to the hospital on multiple occasions. The resident, who was cognitively intact, had a history of diabetes, cerebral infarction, bipolar disorder, and chronic obstructive pulmonary disease (COPD). The resident's clinical records indicated several hospitalizations, but lacked documentation of written notifications for these transfers. The resident was hospitalized on several occasions, including unplanned discharges to a short-term general hospital. Despite these hospitalizations, the resident's records did not contain progress notes detailing the circumstances of the transfers, nor evidence of written notifications being provided to the resident or their representative. Additionally, there was no documentation that the Ombudsman for LTC was informed of these transfers, which is a requirement to ensure the resident's rights and needs are addressed. Interviews with the facility's administrator and director of social services confirmed that the required notifications were not completed. The administrator acknowledged that the floor nurses should have completed the notice of transfer forms, and the director of social services confirmed that the ombudsman was not notified of the resident's hospitalizations. The facility's policy indicated that notifications should be provided as soon as practicable, but this was not adhered to in the cases reviewed.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of a bed hold at the time of transfer for hospitalization for a resident reviewed for hospitalization. The resident, who was cognitively intact, had multiple diagnoses including diabetes, cerebral infarction, bipolar disorder, and COPD. The resident experienced several hospitalizations over a period of time, but the facility did not provide the required bed hold notices during these transfers. The resident's clinical records indicated multiple hospitalizations, including both planned and unplanned discharges to short-term general hospitals. Despite the anticipation of the resident's return to the facility, there was no evidence in the records that a bed hold notice was provided to the resident or their responsible party at the time of each transfer. This lack of documentation was consistent across several hospitalizations, indicating a pattern of non-compliance with the facility's policy. Interviews with the facility's administrator and the director of social services confirmed that bed hold notices were not provided as required. The facility's policy, revised in October 2022, mandates that residents receive written notice about bed hold policies at least twice, including at the time of transfer or within 24 hours in emergency situations. However, this procedure was not followed, as evidenced by the absence of bed hold notices in the resident's records.
Failure to Discontinue Contraindicated Cream for Resident
Penalty
Summary
The facility failed to follow physician orders for a resident with skin conditions, leading to the application of a contraindicated cream. The resident, who was cognitively intact and had a medical history including diabetes, stroke, bipolar disorder, and COPD, experienced adverse reactions after the application of ammonium lactate cream. Despite the resident's complaints of numbness and pain, and a subsequent hospital visit, the facility continued to apply the cream on two occasions after the wound clinic advised discontinuation due to blistering and pain. The resident's condition was observed to include swollen, red lower extremities with multiple blisters. The wound clinic provided a new skin care plan, which included avoiding ammonium lactate, using mild compression, and moisturizing with specific lotions. However, the facility's documentation failed to reflect the discontinuation of ammonium lactate, and the cream was applied contrary to the updated care plan. The Director of Nursing confirmed the oversight and acknowledged that the order should have been clarified or held if there was uncertainty.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control measures during wound care for a resident with a stage 4 pressure ulcer. The resident, who had intact cognition and diagnoses including diabetes mellitus, heart failure, and hypertension, required daily dressing changes for a sacral ulcer. During an observation, two LPNs performed a dressing change without removing a soiled chux pad that had a brown and grayish tan substance on it. Additionally, a fan was left on and blowing directly at the resident's exposed wound, which could potentially introduce bacteria or debris into the wound. The LPNs did not ask the resident for permission to turn off the fan, nor did they date or initial the new dressing after application. Interviews with the LPNs revealed that they did not attempt to remove the soiled chux pad or turn off the fan due to the resident's preferences, although they did not ask for permission to do so. The DON stated that her expectations were for staff to remove all soiled chux pads, date and initial dressings, and ensure fans are turned off during dressing changes to prevent contamination. The facility did not provide a policy regarding wound dressing changes by the end of the survey.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two residents, who were reviewed for immunizations, were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. Resident 2, who was diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, had received the PPSV23 and PCV13 vaccines but lacked evidence of shared clinical decision-making with a physician for the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. Similarly, Resident 3, with chronic respiratory failure and heart failure, also lacked documentation of shared clinical decision-making for the PCV20 vaccine, despite having received the PPSV23 and PCV13 vaccines. The Director of Nursing/Infection Preventionist confirmed that both residents had not been offered or provided education on the PCV20 vaccine, nor was there any shared clinical decision-making with their providers regarding pneumococcal immunizations. The facility's policy, revised in March 2022, stated that all residents should be offered pneumococcal vaccines in accordance with current CDC recommendations, highlighting a failure to adhere to this policy. This oversight was verified during an interview with the DON/IP, who acknowledged the importance of offering the PCV20 vaccine to eligible residents to maintain their health.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Brighton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villas At New Brighton | 0.3 mi | ★★★★★ | 17 | 1 |
| Benedictine Health Center Innsbruck | 1.5 mi | ★★★★★ | 17 | 0 |
| Presbyterian Homes Of Arden Hills | 1.8 mi | ★★★★★ | 3 | 0 |
| St Anthony Health & Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Crest View Lutheran Home | 2.2 mi | ★★★★★ | 2 | 0 |
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