Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Villas At Robbinsdale during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and newly identified elopement risk repeatedly attempted to leave, triggered exit alarms, and expressed a desire to go home, yet the care plan contained only a wander device and general alarm-response directions without specific supervision or individualized interventions. Over the course of an evening, video showed the resident making multiple exit attempts that staff redirected before ultimately leaving through an exit door unobserved and being found by police several blocks away. Agency NAs on duty were not informed which residents were at risk for elopement, and their care sheets did not list elopement risks or related interventions. Additional cognitively impaired residents assessed as elopement risks also had care plans limited to wander devices and general monitoring, with NA care sheets that either omitted elopement risk or lacked preventive interventions, demonstrating a broader failure to translate elopement assessments into clear, supervised care.
Surveyors identified that the facility’s written assessment did not include required elements for staffing recruitment, retention, and contingency planning, despite affecting all 71 residents. The documented assessment omitted a plan to maximize recruitment and retention of direct care staff and did not address how direct care nurse staffing or other care resources would be managed during non-emergency events that could impact resident care. During an interview, the administrator reported having a recruitment plan but confirmed it was not included in the facility assessment and that there was no documented staff retention or non-emergency staffing plan; a requested policy on the facility assessment process was not provided.
The facility failed to verify that an agency nurse aide had an active status on the Minnesota Nursing Assistant Registry before assigning her to a 7.5-hour day shift on a floor caring for multiple residents. The aide reported it was her first shift at the facility, and a registry search later showed her status had been inactive for over a year. The DON stated she relied on the staffing agency to send only registry-listed staff and acknowledged the facility did not verify active status for agency personnel, and the administrator confirmed that their process did not include checking current certification of agency aides. A requested facility policy related to this verification process was not provided.
Failure to timely report alleged physical abuse: A resident with diagnoses including vertebral fracture, DM, depression, and HTN reported that a staff member picked her up, threw her on the floor, and then threw her back onto the bed. The resident also had increased confusion, falls, and new L leg pain noted during an ACP visit. Facility interviews showed the allegation was not reported to the SA within the required 2-hour timeframe, despite the facility policy requiring suspected abuse to be reported promptly.
A resident with a history of fractures, diabetes, depression, hypertension, and fall risk had multiple falls and then showed confusion, weakness, lethargy, and pain. The record lacked evidence of ongoing neuro checks with VS and an assessment for change in condition after the falls, despite therapy notes, ACP input, and family reports describing the resident as unwell, delusional, and later found with bruising, a broken hip, fractured ribs, and a UTI.
Soiled linens, including towels and a shower curtain, were observed unbagged in a bin below the laundry chute. A laundry assistant confirmed that some items were sent down the chute without being bagged. Both the environmental director and infection preventionist stated that all soiled linens should be bagged before being sent down the chute to prevent contamination, but no facility policy was provided.
Surveyors identified failures in proper food labeling and dating in community refrigerators, inadequate maintenance of required food temperatures on a steam table, and unsanitary handling of serving dishes during food prep. The Dietary Manager confirmed that these practices did not meet facility policies for food storage, temperature control, and hygiene.
Two residents received meals that were not at safe or appetizing temperatures, with hot foods served below 135°F and milk above 41°F. Both residents and a family member reported that food was cold or warm by the time it was delivered. Staff interviews revealed uncertainty about required food temperatures, and observations confirmed that food was not held or served at appropriate temperatures, potentially affecting all residents on the unit.
A nurse failed to instruct a resident with cognitive impairment and asthma to rinse her mouth after receiving Budesonide via nebulizer, despite facility policy and medication instructions requiring this step to prevent infection. Staff interviews and observations confirmed the resident was able to rinse and spit, and that rinsing after steroid inhalation is standard practice.
A resident with moderate cognitive impairment and a history of falls did not consistently receive all care plan interventions intended to prevent falls. Staff failed to keep the resident's door open as required, and some were unaware of all necessary fall prevention measures. The care plan and documentation were not fully followed, and the facility could not provide a fall policy when requested.
A resident with COPD, asthma, and diabetes did not receive a newly prescribed inhaler because the medication order was not confirmed in the eMAR system, despite the medication being available in the facility. Staff interviews revealed a lack of awareness and follow-through, resulting in the resident missing doses as the order remained in 'Pharmacy Pending Confirmation' status.
A resident refused Lovenox injections on multiple occasions, but the facility failed to notify the medical provider as required. The resident's care plan did not mention anticoagulation therapy, and staff interviews confirmed the oversight in communication and documentation.
A resident with a surgical wound and fistula did not receive the ordered wound care due to the facility's failure to enter hospital discharge orders into the medical record. The care plan lacked necessary interventions for pouch changes and wound dressings, leading to skin irritation and bleeding. Staff interviews revealed that the process for entering hospital orders was not followed, resulting in incomplete wound assessments and care.
A resident with a surgical wound did not receive proper care due to an LPN's failure to perform hand hygiene between glove changes and after handling contaminated items. Despite recent staff education on hand hygiene, the LPN did not follow the facility's policy, which requires handwashing before and after treating wounds and handling waste.
A resident with peripheral vascular disease and diabetes experienced skin breakdown due to the facility's failure to conduct weekly skin inspections and inform the interdisciplinary team. Despite a care plan requiring daily monitoring, the resident returned from a leave of absence with excoriated skin, which was not documented or addressed. The occupational therapist was unaware of the issue, and the director of nursing did not report the excoriation as an open area. The facility's policy for skin assessment and wound management was not followed.
The facility failed to maintain cleanliness and regular maintenance of the fourth-floor dining room ice and water dispenser, which had visible sediment build-up. Despite the maintenance light indicating a need for cleaning, supplies were not ordered until after the observation. Staff continued to use the machine, raising infection control concerns.
A resident, dependent on staff for toileting, experienced a delay in incontinence care, waiting about an hour for assistance after activating their call light. Staff were occupied with other tasks, and the requirement for two staff members to assist contributed to the delay. The facility's policy on resident dignity and timely care was not followed.
A facility failed to reassess a resident's ability to self-administer medications and update their care plan. The resident, with multiple diagnoses including dysphasia, was found with unauthorized medications at their bedside, despite an order against it due to choking risks. Staff interviews revealed a lack of recent assessments and documentation regarding the resident's self-administration of outside medications.
A resident with cognitive impairment and multiple health issues was not adequately monitored for skin conditions and weight changes. Despite having a care plan that required regular skin assessments and weight monitoring, the facility failed to document and assess the resident's numerous skin sores and weight fluctuations. Staff interviews revealed inconsistencies in awareness and documentation of the resident's condition, highlighting a lack of proper monitoring and communication.
A resident with significant hearing loss did not receive timely follow-up for recommended hearing aids due to communication issues between audiology and medical records staff. The resident's care plan lacked documentation of communication needs, and there was a delay in obtaining medical clearance for the hearing aids.
Failure to Provide Adequate Supervision and Individualized Elopement Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and individualized, care-planned interventions for residents at risk of elopement. One resident with severe cognitive impairment and a diagnosis of malnutrition was initially assessed on admission as non-wandering and completely dependent for mobility and personal care. However, an elopement assessment completed days later identified this resident as an elopement risk who was able to self-propel a wheelchair, was cognitively impaired, actively exit-seeking, and expressing a desire to go home. The resident’s care plan, initiated after this assessment, included use of a wander device, monitoring the device for proper functioning, and prompt response to door alarms, but it lacked specific supervision measures and individualized interventions tailored to the resident’s escalating exit-seeking behavior. In the days leading up to the elopement, multiple progress notes documented that this resident was wandering up and down the hallway, confused, disoriented, and repeatedly attempting to leave the facility despite staff redirection. On the day of the elopement, documentation indicated the resident was very agitated, wandering into other residents’ rooms, calling the police, stating staff were holding her hostage, and attempting to leave multiple times. Video surveillance from the floor exit area showed the resident making several attempts over the course of the evening to open the stairwell and exit doors, triggering alarms that were reset by staff who redirected her away from the doors. Despite these repeated attempts and clear evidence of escalating exit-seeking, no additional formal interventions beyond the wander device were implemented, and staff did not revise the care plan to include increased supervision or other individualized strategies. Later that evening, the video showed the resident successfully exiting through the floor door without staff present. A police report documented that the resident, who was not dressed for the weather and wearing all black, was later found about five blocks from the facility after knocking on a private residence’s door and asking for help. She was transported to the hospital for evaluation and was discharged in stable condition without injuries. Interviews with staff revealed that agency NAs working that shift were not informed which residents were at risk for elopement and that their care sheets did not identify elopement risks or related interventions. Additional residents assessed as elopement risks also had care plans that included wander devices and general directions to monitor for exit-seeking and answer door alarms, but these plans similarly lacked specific supervision measures and individualized interventions, and NA care sheets did not consistently reflect elopement risk status. The facility’s elopement policy directed staff to establish a process to check bracelet alarm/device batteries according to manufacturer directions, and the user guide for the wander management transmitters required at least weekly testing to verify proper operation. Interviews with nursing and management staff showed inconsistent understanding of responsibilities for testing and ensuring functionality of wander devices, as well as for updating care plans and communicating elopement risk to direct care staff. Some nurses believed only nurse managers or the DON could change care plans, while the DON stated all nurses could make care plan changes. Nurse managers reported that residents at risk for elopement should be noted on NA care sheets, but agency NAs reported they were not alerted to any residents at risk to wander or elope. These documented gaps in assessment translation to care plans, supervision, communication, and device management contributed to the resident’s elopement and the identified deficiency. Three additional residents identified as elopement risks had diagnoses including dementia, moderate to severe cognitive impairment, and conditions such as breast cancer and acute encephalopathy. Their elopement assessments indicated confusion, disorientation, and requests to go home. Their care plans directed use of wander devices, monitoring and documentation of exit-seeking behavior, prompt response to door alarms, and inviting them to activities, but similarly lacked explicit supervision requirements and individualized interventions to prevent elopement. NA care sheets for these residents either did not indicate elopement risk or did not include interventions to prevent elopement. These findings showed that the facility failed to consistently integrate elopement risk assessments into clear, individualized supervision strategies and to communicate those strategies to all staff responsible for resident care.
Removal Plan
- Audited the care plans of residents identified as elopement risks
- Provided education to staff regarding the elopement policy
- Provided education to staff regarding elopement assessments
- Provided education to staff regarding one-to-one supervision
- Provided education to staff regarding safety checks
- Provided education to staff regarding wander device management
- Developed and implemented individualized care plans with interventions including supervision for residents at risk for elopement
Incomplete Facility Assessment for Staffing Recruitment, Retention, and Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that included all required components related to staffing resources. The facility assessment dated 12/17/25 did not contain a plan to maximize recruitment and retention of direct care staff, despite this being a required element. The assessment also lacked a contingency plan for situations that did not trigger the formal emergency plan but could still affect resident care, such as issues with the availability of direct care nurse staffing or other care resources. During an interview on 3/13/26 at 3:32 p.m., the administrator acknowledged that while a recruitment plan existed, it was not incorporated into the written facility assessment, and further stated that the assessment did not include a staff retention plan or a plan to address direct care staffing needs outside of the emergency plan. A policy governing how the facility assessment should be conducted and documented was requested by surveyors but was not provided. This failure had the potential to affect all 71 residents in the facility, as the incomplete assessment did not fully address how necessary staffing resources would be ensured during routine operations, nights, weekends, or non-emergency events that could impact resident care.
Failure to Verify Active Nurse Aide Registry Status for Agency Staff
Penalty
Summary
The facility failed to ensure that a nurse aide had a current competency evaluation on the Minnesota Nursing Assistant Registry before allowing her to work, affecting 1 of 1 nurse aides reviewed for registry verification and potentially all 71 residents. On 3/12/26 at 11:46 a.m., a nursing assistant (NA-A) reported it was her first shift at the facility, and the facility schedule for that date showed she was assigned to work a 7.5-hour day shift on the third floor, where 26 residents resided, with a total facility census of 71 residents. A Minnesota Nurse Aide Registry search, dated 3/13/26 at 11:45 a.m. and provided by the facility, showed NA-A’s registry status as inactive since 12/7/24. During interviews, the DON stated she trusted the staffing agency to send only staff who were on the registry and acknowledged the facility did not verify active status for agency staff, and the administrator confirmed that their process did not include verifying current certification of agency aides and that she expected only currently certified NAs would be sent. A facility policy related to this process was requested by surveyors but was not provided.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of physical abuse to the state agency for 1 of 3 residents reviewed for abuse. The resident’s quarterly MDS indicated she was independent with all ADLs, while her admission record listed diagnoses including fracture of vertebrae, diabetes, depression, and hypertension. Her care plan identified altered mobility and directed staff to assist with transfers and bed mobility. An ACP visit note documented that the resident had increased confusion and falls, expressed concern about how a staff person moved her the previous day, and reported that people were in her bed with her; the note also described her as unkempt, lying in bed in a facility gown, with her head craned to the left and remaining still during the visit. The resident also endorsed new pain in her left leg. During interviews, the SW stated the resident reported that a staff member picked her up and threw her on the floor, then picked her up and threw her back on the bed, and that this allegation was reported to the state agency later that evening after it was first reported that morning with the family member present. The administrator acknowledged that abuse allegations should have been reported within two hours, but said the issue was that the family member insisted the resident was confused. The ACP-SW stated she had reported the care concern to the LSW after the visit, and the LSW stated she did not report the pain concern to anyone because the ACP-SW said she had already spoken to someone. The facility policy required suspected abuse to be reported to the state agency no later than two hours after forming the suspicion.
Failure to Document Ongoing Assessment After Resident Falls
Penalty
Summary
The facility failed to provide evidence of ongoing clinical assessments after a resident experienced falls. The resident had diagnoses including a vertebral fracture, diabetes, depression, and hypertension, and her care plan identified a fall risk, altered mobility, and the need for staff assistance with transfers and bed mobility. Her record showed multiple falls, including being found on the floor with bruising to the right elbow and another fall where she was found on the floor and reported wanting to get out of bed and go home. After the falls, the record documented limited follow-up. One note stated a neurological flow sheet for fall follow-up showed vital signs within normal range and hourly checks were performed, but the resident’s medical record lacked evidence that neurological checks with vital signs were completed as directed or that an assessment was done related to a change in condition. Therapy notes described the resident as shaky, unable to lift her head or keep her eyes open, and later still looking unwell after another fall. An ACP visit note also described increased confusion and falls, unkempt appearance, pain in the left leg that was new, and concern that delirium was likely. Family and staff interviews described the resident as increasingly confused, weak, lethargic, and in pain after the falls. A family member reported the resident was found curled in bed in dirty sheets with blood on the floor, was not responding, and later had bruising on one whole side of her body, a broken hip, fractured ribs, and a UTI. The DON stated that after a fall staff should assess the resident and complete neurological checks for 72 hours, but he had not seen the neurological flow sheet and did not know where it was. The record also showed the resident was transferred to the hospital for weakness, confusion, and lethargy and later discharged from the facility.
Improper Handling of Soiled Linens in Laundry Process
Penalty
Summary
The facility failed to ensure that soiled facility linens were handled in a manner that prevented potential contamination during the laundry process. During an observation, three towels and a shower curtain were found unbagged and lying in a bin below the laundry chute. The laundry assistant confirmed that some laundry items were sent down the chute without being bagged. The environmental director and infection preventionist both stated that soiled linens should be bagged before being sent down the chute to prevent contamination and potential exposure to infection. The facility was unable to provide a policy regarding the proper handling of soiled linens in relation to the laundry chute.
Deficiencies in Food Labeling, Temperature Control, and Sanitary Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in community refrigerators on two of three floors where residents' personal food was kept. Observations revealed undated and unlabeled containers, including a plastic bag with a Tupperware container, a half-full plastic pitcher with orange liquid, and a container of ice cream dated nearly two months prior. Additionally, an unlabeled and undated container of cooked pasta was found. The Dietary Manager confirmed these items were for resident consumption and acknowledged they should have been labeled and dated according to facility policy. During food service, a dietary aide recorded a chicken temperature of 120°F on the steam table, which was below the required standard. The Dietary Manager verified the temperature and instructed the aide to reheat the chicken, confirming that no residents had been served the underheated food. In the kitchen, another dietary aide was observed prepping fruit without gloves and touching the inside of serving bowls with their thumb, which the Dietary Manager confirmed was not in line with sanitary practices. These actions were inconsistent with the facility's policies on food storage, temperature maintenance, and hygiene during food preparation.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for two residents on the second floor. Both residents, one with intact cognition and one with moderate cognitive impairment, reported that their meals were not at appropriate temperatures when delivered to their rooms. One family member also stated that food was usually cold by the time it reached the resident. Observations confirmed that food was plated and placed on a cart, then delivered to the second floor, where the last tray was served with food temperatures below required standards: chicken at 106°F, rice at 119°F, mashed potatoes at 127°F, and milk at 55°F. The surveyor noted that the hot foods were cold or lukewarm, and the milk was warm. Interviews with staff revealed a lack of knowledge regarding proper food holding temperatures. Both a nursing assistant and a dietary aide were unsure of the required temperatures for hot and cold foods. The dietary manager stated that hot foods should be held at a minimum of 135°F and cold foods at 41°F or lower, consistent with the facility's policy, which also identified the danger zone for food temperatures as between 41°F and 135°F. The failure to maintain appropriate food temperatures had the potential to affect all 24 residents on the unit.
Failure to Instruct Resident to Rinse Mouth After Steroid Nebulizer Administration
Penalty
Summary
A deficiency occurred when a registered nurse administered Budesonide inhalation suspension via nebulizer to a resident with cognitive impairment, dementia, anxiety, and asthma, but failed to instruct or assist the resident to rinse her mouth after the medication. The resident's care plan required staff to administer medications as ordered, and the medication's instructions specified that the mouth should be rinsed after inhalation to prevent fungal infections. During the observed medication administration, the nurse placed the nebulizer mask on the resident and returned after the treatment, but did not instruct or assist the resident to rinse her mouth. The nurse later confirmed she had not provided this instruction and was unsure if the resident was able to rinse and spit, despite the resident's demonstrated ability to do so during a subsequent observation with a nursing assistant. Interviews with facility staff, including a licensed practical nurse, pharmacy consultant, and director of nursing, all confirmed the importance of rinsing the mouth after steroid nebulizer use to prevent infections such as thrush. The facility's policy required all medications to be administered in a safe and effective manner. The failure to follow this standard of practice for medication administration resulted in the facility not meeting professional standards of quality for this resident.
Failure to Follow Fall Risk Interventions for High-Risk Resident
Penalty
Summary
Staff failed to consistently implement fall risk interventions for a resident identified as being at high risk for falls. The resident had moderate cognitive impairment, required extensive assistance with activities of daily living, and had a history of falls, as well as diagnoses including diabetes mellitus and depression. The care plan specified several interventions, such as keeping the bed in the lowest position, placing a fall mat next to the bed, keeping the door open when the resident was in the room, posting a 'do not fall' sign, and ensuring the call light was within reach. Additionally, staff were to check on the resident and offer bathroom assistance during specific hours. Despite these interventions, multiple falls occurred over several months, each time prompting additional interventions to be added to the care plan. Observations revealed that the resident was found in bed with the door closed, contrary to the care plan instructions. Interviews with nursing staff indicated a lack of awareness of all required interventions, with some staff only aware of the bed and mat requirements and not the need to keep the door open or other measures. The nursing assistant worksheet lacked comprehensive fall interventions, and the facility was unable to provide a fall policy when requested. The DON confirmed that staff were expected to follow care plans at all times, but this was not consistently done for this resident.
Failure to Administer Ordered COPD Medication Due to System Lapse
Penalty
Summary
The facility failed to implement a system to ensure that medications were available and administered as ordered for a resident with significant medical needs. The resident, who was cognitively intact and dependent on staff for dressing and toileting, had diagnoses including asthma, COPD, and diabetes mellitus. A physician order was placed for Anoro Ellipta, a medication used for COPD, but review of the electronic medication administration record (eMAR) showed that the medication remained in 'Pharmacy Pending Confirmation' status and was not administered as prescribed. The medication was present in the facility, but the order had not been confirmed in the system, resulting in the resident not receiving the medication since it was prescribed. Interviews with facility staff revealed a lack of awareness and follow-through regarding the medication order. The registered nurse acknowledged the medication was in the cart but had not been confirmed or given. The DON was unaware that the medication had not been confirmed or administered, and the consultant pharmacist stated that confirmation should have occurred promptly. The facility's policy required timely and accurate transcription of medication orders, but this was not followed, leading to the deficiency.
Failure to Notify Provider of Medication Refusal
Penalty
Summary
The facility failed to notify the medical provider of a resident's refusal to take Lovenox, a medication used to prevent blood clots following surgery. The resident, who was cognitively intact and had a surgical wound, was prescribed Lovenox to be administered daily. However, the Medication Administration Record (MAR) indicated that the resident refused the medication on multiple occasions, specifically from February 6 to February 8 and from February 11 to February 16. Despite these refusals, there was no documentation that the medical provider was informed, as required by the facility's procedures. Interviews with staff revealed that the registered nurse and the director of nursing acknowledged the oversight, confirming that the provider should have been notified immediately upon the resident's first refusal. The facility's Specific Medication Administration Procedure mandates that persistent medication refusals be documented and communicated to the physician or prescriber. The resident's care plan also lacked any mention of anticoagulation therapy, further highlighting the deficiency in communication and documentation regarding the resident's medication management.
Failure to Provide Ordered Wound Care for Resident
Penalty
Summary
The facility failed to provide wound care as ordered for a resident, identified as R2, who was admitted with a surgical wound and required non-surgical dressings. R2's hospital discharge orders included specific instructions for wound care management, which were not entered into the facility's provider orders upon admission. This oversight resulted in the absence of necessary wound care and pouch changes for R2's fistula, as indicated in the hospital discharge orders. R2's care plan did not reflect the required wound care and pouch changes, and the Skin and Wound Evaluation lacked comprehensive documentation of the wound's condition. The wound provider's progress note highlighted a treatment error, noting that R2 had not been receiving the required dressing changes every six hours, leading to skin irritation and bleeding. Despite the presence of a care plan indicating R2's ability to direct her stoma care, the interventions did not include assistance with pouch changes and wound dressings. Interviews with facility staff, including registered nurses and the director of nursing, revealed that the process for entering hospital orders was not followed correctly, resulting in the omission of R2's wound care orders. The director of nursing acknowledged that the admission wound care orders were not entered into the medical record, and staff did not perform the care as ordered. Additionally, the wound assessment conducted on 2/13/25 was incomplete, failing to assess R2's wound/fistula adequately.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to conduct appropriate hand hygiene during wound care for a resident who was cognitively intact and had a surgical wound requiring non-surgical dressings. During an observation of the wound care process, an LPN was noted to have washed his hands with soap and water before starting the procedure. However, the LPN did not perform hand hygiene between glove changes while handling a fistula collection bag containing stool, cleaning the resident's legs, and managing wound care supplies. The LPN also failed to perform hand hygiene after touching a receptacle that previously held stool and after leaving the resident's room. The LPN acknowledged during an interview that he did not perform hand hygiene as required, except before starting the wound care. The director of nursing confirmed that staff had been educated on hand hygiene recently and were expected to follow the facility's hand hygiene policy. The facility's handwashing policy indicated that proper handwashing should be performed before and after treating a wound, after cleaning up someone who has used the toilet, and after touching garbage. The policy also required handwashing before donning gloves and after removing them during procedures requiring glove use.
Failure to Monitor and Address Resident's Skin Breakdown
Penalty
Summary
The facility failed to ensure that a resident with peripheral vascular disease and diabetes with neuropathy received appropriate skin care and monitoring, leading to skin breakdown. The resident, who was dependent on staff for mobility and hygiene, had a care plan that required daily skin monitoring and weekly skin inspections. However, the facility did not complete these inspections or inform the interdisciplinary team of the resident's skin breakdown. During a care conference, a family member mentioned a wound, which was not previously noted by therapy staff. The resident returned from a leave of absence with excoriated skin on the thighs, but no further documentation of care for the skin breakdown was provided. Observations and interviews revealed that the resident experienced discomfort from sitting in a wheelchair and had excoriated areas on the buttocks and thighs. The occupational therapist was unaware of the skin breakdown, and the registered nurse noted the excoriation but did not measure it. The director of nursing acknowledged the excoriation but did not report it as an open area. The facility's nurse consultant stated that the director of nursing should have addressed the skin concerns in daily meetings and updated the care plan accordingly. The facility's policy required staff to notify the provider, update the care plan, and involve therapy for skin concerns, which was not followed in this case.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and regular maintenance of the fourth-floor dining room ice and water dispenser, which was observed to have white, speckled, crust residue on various surfaces. The maintenance director (DOM) acknowledged that the machine's maintenance light had indicated a need for cleaning, but supplies for cleaning and sanitizing were not ordered until after the observation. The DOM, who started working at the facility in March 2024, stated this was the first time they would be cleaning and sanitizing the dispenser. Despite the visible sediment, staff continued to use the machine, and the administrator confirmed the presence of sediment and expected maintenance to address it when triggered by the facility's communication system. The facility's policy required ice machines to be cleaned and sanitized per manufacturer's instructions, which recommended cleaning at least every six months or more frequently based on water mineral content and other factors. The last recorded cleaning of ice machines and bins was on 5/31/24. The administrator noted that the fourth-floor machine had two filters to counter hard water sediment build-up, with one filter dated 3/28/24. The failure to clean and sanitize the machine as required raised infection control concerns, as staff continued to use the machine for resident meal service.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for a resident, compromising their dignity. The resident, who was cognitively intact and dependent on staff for toileting due to frequent incontinence, reported not being changed since the morning and activated their call light for assistance. A trained medication aide responded but left the room after informing the resident that another staff member would assist them. However, the resident had to wait for approximately an hour before two nursing assistants arrived to change their incontinence brief. Interviews with staff revealed that the delay was due to other staff being occupied with different tasks or on break, and the requirement for two staff members to assist with the resident's care. The registered nurse and director of nursing acknowledged that the call light should remain on until the resident's needs are met and that the delay in care could impact the resident's dignity. The facility's policy emphasizes the importance of upholding residents' rights to dignity and timely care, which was not adhered to in this instance.
Failure to Reassess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to comprehensively reassess a resident's ability to safely self-administer medications, document resident education regarding the risks, and update the care plan accordingly. The resident, who was cognitively intact and had multiple diagnoses including dysphasia, malnutrition, ADHD, depression, and anxiety, was observed to have medications at their bedside. These included guaifenesin, eye drops, ear wax remover, and nystatin powder, which were not authorized for self-administration according to the facility's policy. The resident's medical record lacked additional assessments beyond an initial evaluation that deemed them capable of self-administering certain medications. Despite this, there was an order indicating that medications should not be left in the resident's room due to the risk of choking, as the resident preferred to lie in bed rather than sit upright. Staff interviews revealed that the resident had a history of obtaining medications from outside sources, and there was no recent assessment or documented risk/benefit discussion regarding these outside medications. The facility's policy required a comprehensive assessment by the interdisciplinary team to determine if self-administration was safe and appropriate, with periodic reassessments based on changes in the resident's status. However, the resident had not been recently reassessed, and the care plan was not updated to reflect the medications they could self-administer. The presence of unauthorized medications at the bedside was not addressed by staff, despite being in plain view, leading to concerns about potential interactions and safety risks.
Failure to Monitor Skin Conditions and Weights
Penalty
Summary
The facility failed to comprehensively assess and monitor non-pressure related skin conditions and resident weights for a resident identified as R40. R40, who was cognitively impaired and had a history of alcohol use disorder, depression, cellulitis, and incontinence, was admitted to the hospital with severe dehydration and other symptoms. Upon discharge, R40's care plan included monitoring skin integrity and performing weekly skin inspections, but the facility did not adequately document or assess R40's skin conditions, which included open abrasions and scabs on various parts of the body. Despite the care plan's instructions, the facility's documentation lacked consistent identification and assessment of R40's skin issues. Observations revealed numerous scabs and open sores on R40's body, which were not consistently documented or monitored. Interviews with staff indicated a lack of awareness and documentation regarding R40's skin conditions, with some staff unsure of the status of the sores and others acknowledging the absence of proper documentation and monitoring. Additionally, the facility failed to monitor R40's weight as required, particularly given the resident's use of diuretics and history of weight fluctuations. Although R40's weight was recorded at two points, there was no consistent monitoring or documentation of weight changes, which was crucial due to the resident's medical conditions and medication regimen. The lack of weight monitoring was attributed to agency staff not entering the order for weights, leading to a failure in triggering the necessary monitoring procedures.
Failure to Provide Timely Hearing Aid Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received proper follow-up for recommended hearing assistive devices. The resident, who had intact cognition and diagnoses including Alzheimer's dementia, anxiety, and high blood pressure, was identified as hard of hearing but did not wear hearing aids. An audiology exam revealed significant sensorineural hearing loss in both ears, and hearing aids were recommended. However, the resident's care plan lacked documentation of communication needs, and there was a delay in obtaining medical clearance for the hearing aids. The delay was attributed to communication issues between the audiology staff and the facility's medical records (MR) staff. The MR staff acknowledged missing the notification for medical clearance and stated that the request was only sent to the resident's provider months after the audiology exam. Interviews with staff, including the MR staff, social services, a registered nurse, and the director of nursing, confirmed the breakdown in communication and the lack of timely action on the audiology recommendations. The facility did not provide a policy on appointment follow-up or hearing and communication when requested.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,028 citations issued within 25 miles in the last 12 months — including the 31 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Robbinsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Specialty Care Community | 0.8 mi | ★★★★★ | 26 | 0 |
| Courage Kenny Rehabilitation Institutes Trp | 0.9 mi | ★★★★★ | 7 | 1 |
| The Terrace At Crystal Llc | 1.2 mi | — | 65 | 4 |
| Covenant Living Of Golden Valley Care & Rehab Ctr | 1.6 mi | ★★★★★ | 2 | 0 |
| Villas At Bryn Mawr Llc | 2.5 mi | ★★★★★ | 5 | 3 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.