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 The Villas At The Park during CMS and state inspections, most recent first.
Failure to Provide ROM Interventions Led to Severe Contractures: A resident admitted without contractures was not placed on a ROM or restorative program, and the care plan lacked interventions to prevent contractures. Staff and the hospice RNCM stated ROM and therapy were not provided while the resident was on hospice, and the DON and provider believed the contractures worsened during that time. After hospice revocation, the resident was observed in a fetal position with severe contractures of all extremities, grimacing during care, and OT/PT documented fixed flexion contractures that prevented sitting, standing, or ambulation.
Resident personal and medical information was left exposed on an unattended med cart in a hallway, including a care sheet with multiple residents' names, room numbers, tube feeding, blood sugar, BP, HR, falls, confusion, and adaptive equipment details, plus EMR login credentials and an open narcotic logbook with two residents' narcotic dosage information. RN-A acknowledged the cart should not have been left open because of HIPAA, and the DON stated resident information was expected to be covered and secured.
A resident with moderate cognitive impairment and post-stroke deficits reported that staff told him to wet himself when he asked to use the toilet, despite being able to sense when he needed to urinate and preferring a urinal or the toilet. OT and nursing staff stated he could indicate the need to void and needed assistance placing the handheld urinal, and the LPN confirmed it was never okay to tell a resident to wet himself. The facility policy required person-centered care that honors resident preferences and choices.
Failure to obtain and document informed consent for psychotropic medications was identified for two residents. One resident with severely impaired cognition, schizophrenia, and a feeding tube received Haloperidol via G-tube multiple times without a signed consent or documentation that risks, benefits, and alternatives were discussed with the resident representative. Another resident with moderate cognitive impairment received Seroquel nightly without evidence of advance education or consent, and the DON stated consents were not completed because the meds had been started in the hospital.
A resident with moderate cognitive impairment and a stroke-related diagnosis received Seroquel 12.5 mg nightly, but the EMR lacked documentation of an appropriate diagnosis and indication for use. The MAR showed the resident received the antipsychotic every evening, and an LPN confirmed the indication was not documented as expected during admission review.
Failure to provide and care plan activities for a bed-bound resident. A resident with aphasia and hemiplegia/hemiparesis was not assessed for activity preferences, and his care plan was not updated after hospice discharge. Observations showed him lying in bed awake without music, TV, or other stimulation, while staff stated he no longer got out of bed or attended activities. The TRD confirmed he had been in bed for quite some time, and the DON said she believed he had a radio with CDs from hospice.
A resident with severe cognitive impairment, dysphagia, a mechanically altered diet, and tube feedings was observed being fed by the SSD while lying in bed with the HOB at 30 to 45 degrees. The SSD was not a CNA, was not formally certified to feed residents, and the facility confirmed it did not employ paid feeding assistants. The resident’s care plan and ST note required staff assistance and safe positioning during meals, but the facility allowed an unqualified staff member to provide feeding assistance.
A resident with intact cognition was found to have an arbitration agreement in the EMR that was electronically signed by the resident and the SS-D, but the resident stated no one discussed arbitration with her and she did not sign the paperwork. The SS-D and administrator both expressed confusion about the signatures and dates in the admission packet, and the resident’s family contact stated the resident would remember whether she agreed to arbitration.
Two residents at a facility developed worsening pressure ulcers due to inadequate assessment and intervention. One resident's deep tissue injuries progressed to unstageable pressure injuries due to lack of repositioning and heel protection. Another resident's stage two ulcer worsened due to insufficient nutritional support and intervention. The facility failed to implement necessary preventive measures, leading to deterioration in both residents' conditions.
A resident with intact cognition and multiple respiratory conditions was observed with an Advair inhaler at their bedside without a proper self-administration assessment or physician's order. The facility's policy required a completed assessment and order for self-administration, which were not in place for the Advair inhaler. Staff interviews confirmed the lack of documentation and awareness regarding the resident's ability to self-administer this medication.
A resident with severe cognitive impairment and a history of hallucinations was found to have restricted movement due to pillows placed under the fitted sheet of their bed, blocking the egress section of a perimeter mattress. This intervention was not documented in the care plan, and staff were unaware of its use as a fall prevention measure. Interviews revealed that the use of pillows was not a recognized intervention, and the facility's policy lacked guidance on ensuring interventions were not restraints.
The facility failed to implement physician orders for compression stockings for two residents with edema. One resident, with heart failure and brain neoplasm, was often without stockings due to lack of documentation and staff confusion. Another resident, with chronic venous insufficiency, also lacked proper documentation and was not wearing compression socks as required. Staff interviews revealed a lack of awareness and adherence to orders, highlighting a deficiency in care practices.
A resident with hemiplegia did not receive the ordered hand splint program due to discomfort and lack of follow-up by the facility. The care plan required a splint to prevent contractures, but the resident reported pain, and the program was not consistently implemented. Staff were unaware of the program, and documentation lacked evidence of refusal or rationale for discontinuation. Observations showed the resident's hand was contracted, and there was no policy provided for assistive devices.
A resident with a history of falls did not receive necessary fall prevention interventions, such as non-slip tape, despite being identified as at risk. The care plan and care guide lacked specific fall prevention measures, and staff interviews confirmed the oversight. Observations showed that planned interventions were not implemented, leading to a fall incident.
A resident with pressure injuries and an indwelling catheter did not receive proper infection control measures during wound and catheter care. Staff failed to use enhanced barrier precautions (EBP) and did not follow the facility's catheter care policy, which included using a barrier and alcohol wipes. The facility's policies were not fully implemented, leading to deficiencies in infection control practices.
A facility failed to regularly inspect bed rails, leading to a deficiency. A resident with Alzheimer's and mobility issues had a loose bed rail missing a lock, despite having a physician's order for grab bars. Staff interviews revealed inconsistent inspection practices, and the facility lacked documentation of regular checks. This oversight resulted in the deficiency as the facility did not ensure the safety and maintenance of bed rails.
Failure to Provide ROM Interventions Led to Severe Contractures
Penalty
Summary
The facility failed to ensure a resident received appropriate interventions to maintain range of motion and prevent contractures. The resident was admitted without contractures and had diagnoses including aphasia, hemiplegia, and hemiparesis following a stroke. Early MDS assessments indicated the resident was not on any range of motion or restorative nursing program, and the care plan did not include interventions to prevent contractures. A later balance/ROM assessment documented no impairment in the upper or lower extremities, including the shoulders, elbows, wrists, hands, hips, knees, ankles, and feet. After the resident was admitted to hospice, staff and the provider stated that therapy and/or range of motion services were not provided because the resident was on hospice. The hospice RNCM stated that when she began managing the resident, he could stand and pivot transfer and did not have contractures, but over time his legs became progressively more contracted until they could no longer be straightened. The DON and provider stated they believed the resident’s contractures worsened during hospice and that no ROM program had been initiated, with the provider noting she assumed hospice was addressing those needs. Following hospice revocation, the resident was observed lying in bed in a fetal position, and nursing staff noted severe contractures of the bilateral upper and lower extremities. During care, staff had to roll him side to side for peri care, and he grimaced and called out in distress. Therapy documentation later confirmed contractures in all extremities, including fixed flexion contractures of both lower extremities and the left upper extremity, and OT documented that the resident could not sit unassisted and could not be assessed for standing or ambulation because of the severity of the contractures.
Resident Information Left Exposed on Medication Cart
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when an unattended medication cart was left in the hallway corridor with resident information exposed. During observation, a form titled East nursing care sheet was visible on the cart and contained 13 resident names, room numbers, and personal care details such as tube feeding, blood sugars, blood pressures, heart rates, recent falls with confusion, and use of adaptive equipment. The same cart also had EMR access username, password, and wifi information displayed, and an opened narcotic logbook was visible with two residents' names, room numbers, and narcotic dosage information. Two residents and one staff member walked past the unattended cart while the information was exposed. RN-A later stated she was responsible for the cart and acknowledged that it should not have been left open because of HIPAA, and that the narcotic logbook should have been closed so the information was not visible to anyone walking by. The DON stated that patient information was expected to be covered and secured. Facility policy titled HIPAA and Confidentiality of Client Matters stated that resident rights and HIPAA privacy and security standards require protection of and restriction on disclosure and use of clients' individual health information.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
The facility failed to ensure a resident with continent bladder function was assessed and care planned for a dignified toileting experience after he reported being told to wet himself when asking to use the toilet. The resident was admitted with moderate cognitive impairment, extensive assistance needs for most ADLs, and a diagnosis of sequelae of cerebral infarction. His bladder evaluation identified functional incontinence related to impaired mobility, manual dexterity impairment, lack of toilet or toilet substitute, use of restraints, and medications, and his care plan noted he transferred with assistance of an easy stand. During interview, the resident stated he could sense when he needed to urinate, but staff would tell him to wet himself when he asked to use the toilet, and he said it felt awful to urinate in his brief and that he preferred a urinal or the toilet. OT staff stated he had been working on using the urinal, could sit on the side of the bed and shimmy his pants down, and only needed help placing the handheld urinal, adding that floor staff could assist with placement and that it was understandable he was frustrated because staff were telling him to go in his pants when he could control his bladder. NA and RN staff stated he could let them know when he needed to urinate but needed to use his brief because his hands shook and he could not place the handheld urinal on his own. The nurse manager/LPN stated staff were expected to use a bed pan or urinal for a resident asking to use one and confirmed it was never okay to tell a resident to wet himself. The facility policy stated care and services should be person-centered and honor each resident's preferences, choices, values, and beliefs.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including explanation of the risks and benefits, for psychotropic medications for 2 residents. R7 had severely impaired cognition, was dependent for all cares, had diagnoses including anoxic brain damage, seizures, schizophrenia, and dysphagia, and received nutrition through a feeding tube. Physician orders dated 8/18/25 showed Haloperidol 5 mg via G-tube twice daily for schizophrenia/catatonic schizophrenia, and the MAR showed the medication was administered repeatedly from August through November 2025. However, the EMR lacked evidence of a signed consent before the medication was provided and lacked documentation that the risks and expected benefits of the regimen were reviewed or discussed with R7's resident representative, FM-B. R12 was admitted on 10/29/25 with moderate cognitive impairment and had received antipsychotic medication during the 7-day lookback period. Physician orders dated 10/29/25 included Seroquel 12.5 mg at bedtime, and the November MAR showed the medication was administered nightly for 19 doses. The EMR lacked evidence that R12 and/or the representative was informed in advance of the risks, benefits, treatment alternatives, or other options. During interviews, R12 could not recall signing a consent, and the nurse manager and LPN confirmed they could not find a consent for Seroquel. The DON stated informed consents were not completed for R7 and R12 on admission because the medications had been started in the hospital and there was a misunderstanding that consent was only needed if the facility started or increased the psychotropic medication.
Unnecessary Psychotropic Medication Documentation
Penalty
Summary
The facility failed to ensure a resident had an appropriate diagnosis and indication for use for prescribed antipsychotic medication. R12 was admitted on 10/29/25 with moderate cognitive impairment and a primary diagnosis of sequelae of cerebral infarction, and the admission MDS indicated antipsychotic medication use during the 7-day lookback period. Physician orders dated 10/29/25 included Seroquel 12.5 mg at bedtime, and the November MAR showed the resident received Seroquel every evening for a total of 19 doses. However, the EMR lacked evidence of an appropriate diagnosis and indication for Seroquel use. During interview, the nurse manager/LPN confirmed R12 did not have an appropriate diagnosis or indication documented in the EMR for Seroquel and stated medications, including indication for use, would be expected to be reviewed during admission. The facility policy on psychotropic medication use required the indication to be thoroughly documented in the clinical record with an appropriate supporting diagnosis and identification of the behavioral symptoms being treated.
Failure to Provide and Care Plan Activities for a Bed-Bound Resident
Penalty
Summary
The facility failed to ensure that a bed-bound resident was care planned for and received adequate activities for social and mental stimulation. The resident was admitted on 3/20/19, was dependent on staff for all ADLs, and had diagnoses including aphasia and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident’s significant change MDS indicated he was not assessed for activity preferences and that staff did not complete an activity assessment. His activity participation review noted preferences such as listening to favorite music in his room, watching TV, and having visits from hospice staff and his brother. The resident’s care plan stated he was formerly from another country, had been a lawyer for many years, occasionally attended activities but preferred to watch and be in the company of others, and enjoyed people-watching, snacking, resting, reading, relaxing, and painting in the past. However, the most current interventions were dated 9/18/25 and did not reflect updated interventions after he discharged from hospice services on 10/10/25. During observations on 11/17/25, 11/18/25, and 11/19/25, he was lying in bed, often in the fetal position, awake, and without music, TV, or other stimulation in his room. Staff stated he no longer got out of bed or attended activities after revoking hospice, and the TRD confirmed he had been in bed for quite some time and did not provide follow-up information about reassessment or care plan updates. The DON stated she believed he had a radio with CDs from hospice and would care plan for music in his room, while a facility activities policy was requested but not received.
Unqualified staff assisted a resident with feeding
Penalty
Summary
The facility failed to ensure that a resident who required assistance with eating received that assistance from qualified staff. R47’s MDS indicated severe cognitive impairment, dependence on staff for eating assistance, a mechanically altered diet, and use of a feeding tube. The care plan stated that R47 required staff assistance with eating, and the speech therapy discharge note documented dysphagia, respiratory failure, and traumatic brain injury, recommending a minced and moist diet with thin liquids, staff supervision/assistance at mealtime to swallow safely, and positioning at 90 degrees while eating or drinking. The order summary also reflected a minced and moist diet with thin liquids and tube feedings twice daily. During observation, R47 was seen lying in bed with the head of the bed at a 30-to-45-degree angle while the social services director sat beside him and fed him by bringing utensils of food to his mouth. The social services director confirmed he had assisted R47 with eating, stated he had helped residents with feeding in the past, and acknowledged he was not a CNA and was not formally certified to feed residents. The administrator confirmed the facility did not employ paid feeding assistants and stated the social services director had no prior facility training for feeding. The DON stated that only nurses and nursing assistants had met the requirements to feed residents and that the social services director had not met those requirements. A policy on assisting residents with eating was requested but not received.
Arbitration Agreement Not Clearly Communicated Before Signature
Penalty
Summary
The facility failed to ensure that a binding arbitration agreement for one resident was clearly communicated in a form and manner the resident understood before signing. The resident had a quarterly MDS that identified intact cognition with no impairment in memory or mood, and the record showed an admission packet in the EMR that was electronically signed by the resident and the social services director. However, the resident stated she had lived in the facility since January 2023, had no memory issues, understood what arbitration meant, and said no one from the facility spoke with her about signing or agreeing to arbitration in disputes. She also stated she did not sign paperwork or use the computer on the date the packet was signed and was not sure she would agree to arbitration. The resident’s emergency contact stated the resident could remember whether she agreed to arbitration. The social services director stated the usual process was to present a video and explain arbitration to the resident or representative, but after reviewing the resident’s packet, he said the signatures throughout the packet were his and all were dated differently than the resident’s admission date. He also stated he did not recall talking with the resident and did not sign the form that day. The administrator reviewed the packet and stated the admission packet had been audited and downloaded into the EMR, that the social services director had signed the scanned forms, and that it was confusing because he did not remember discussing the form with the resident; the administrator also stated the resident would definitely remember if she had signed the paperwork that day.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess and implement pressure ulcer interventions for two residents identified at risk for pressure ulcers, resulting in actual harm. One resident, referred to as R30, developed two deep tissue injuries that worsened to unstageable pressure injuries on the heels after admission. The facility did not include necessary interventions such as floating heels or a turning and repositioning schedule in the care plan. Despite being at high risk due to limited mobility and other comorbidities, R30 was not repositioned according to the care plan, and the facility failed to accurately assess the resident's sensory perception issues, which contributed to the development of pressure ulcers. Another resident, referred to as R33, developed a stage two pressure ulcer that worsened to an unstageable pressure ulcer. The facility failed to accurately stage the pressure ulcer and did not assess the resident's nutritional needs or implement provider-ordered nutritional interventions to aid in healing. R33 was at risk for pressure ulcers due to extensive assistance needed for bed mobility and incontinence, yet the care plan lacked specific interventions such as a wedge cushion in the bed. The resident experienced weight loss, and the facility did not provide nutritional supplements despite the resident's poor appetite and risk for pressure ulcers. The facility's inaction and lack of appropriate interventions led to the deterioration of the residents' conditions. Observations revealed that staff did not consistently reposition R30 as required, and the resident was not compliant with wearing protective boots, which was not adequately addressed by the facility. The facility's failure to implement timely and effective pressure ulcer prevention measures, such as floating heels and ensuring proper nutrition, resulted in the worsening of pressure ulcers for both residents.
Failure to Ensure Proper Self-Administration Assessment and Physician's Order
Penalty
Summary
The facility failed to ensure a self-administration assessment (SAM) and a physician's order were completed for a resident to safely self-administer their medication. The resident, who had intact cognition and multiple cardiorespiratory conditions, was observed with an Advair diskus inhaler at their bedside. Despite having a physician's order to self-administer a nebulizer after nursing setup, there was no order or assessment for the resident to self-administer the Advair inhaler. The resident's Self Administration of Medication Evaluation form indicated they were capable of self-administering inhalation medication, specifically the nebulizer, but did not include the Advair inhaler. Several checkboxes on the form were left unmarked, indicating incomplete assessment of the resident's ability to self-administer medications. Observations over several days confirmed the presence of the Advair inhaler at the resident's bedside, and staff interviews revealed a lack of awareness and documentation regarding the resident's ability to self-administer this medication. Interviews with facility staff, including a trained medication aide and licensed practical nurses, confirmed that there was no physician's order for the resident to self-administer the Advair inhaler. The facility's policy required a completed SAM and physician's order for self-administration, which were not in place for the Advair inhaler. The director of nursing verified that the SAM evaluation form did not include the Advair inhaler, and the facility's policy on self-administration of medications emphasized the need for a comprehensive assessment and documentation in the medical record and care plan.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed when multiple pillows were placed under the fitted sheet of the resident's bed, blocking the egress section of a perimeter mattress. This setup restricted the resident's movement and was not easily removable by the resident, who was identified as having severely impaired cognition and a history of hallucinations and delusions. The resident, who had a traumatic brain injury and anxiety, required extensive assistance for bed mobility and transfers and was at risk for falls. The resident's care plan and associated documentation did not include the use of pillows as a fall intervention, and there was no evidence of a thorough assessment or interdisciplinary team involvement regarding the use of such restraints. Nursing staff and the resident's guardian were unaware of the pillows being part of the care plan, and the facility's policy on fall prevention lacked guidance on ensuring interventions were not restraints. Observations revealed that the resident attempted to crawl out of bed but was impeded by the pillows, which were placed under the fitted sheet by nursing assistants. Interviews with staff, including registered nurses and the director of nursing, indicated that the use of pillows was not a recognized intervention and could potentially increase the risk of injury or behavioral issues. The physical therapist also noted that the pillows were not a realistic intervention and could hinder mobility. The facility's failure to properly assess and document the use of pillows as a restraint led to the deficiency, as it restricted the resident's freedom of movement without appropriate justification or documentation.
Failure to Implement Compression Stocking Orders for Residents with Edema
Penalty
Summary
The facility failed to implement physician orders for compression stockings for two residents, R40 and R45, who were reviewed for edema. R40 had a medical history including heart failure and brain neoplasm, and required compression stockings as per physician orders to manage lower extremity edema. However, the care plan and nursing assistant care guide lacked documentation of this requirement. Observations revealed that R40 was often without compression stockings, and interviews with staff indicated confusion about who was responsible for applying them. The registered nurse acknowledged that R40 was unable to put on the stockings independently and that the nursing assistants should have been applying them. Similarly, R45, who had chronic venous insufficiency, also required compression socks as per physician orders. However, the facility's records, including the Medical Administration Record and Treatment Administration Record, lacked documentation of the use or refusal of compression socks. Observations showed that R45 was not wearing compression socks, and interviews revealed that staff were unaware of the orders or the location of the socks. The registered nurse and licensed practical nurse confirmed the need for compression socks but noted they were not listed in the care plan or electronic medical record. The director of nursing stated that staff were expected to follow physician orders and document them accordingly, but this was not done for either resident. The facility did not provide a specific policy on edema management, but their policy on Activities of Daily Living indicated that necessary care and services should be provided to maintain or improve residents' abilities. The lack of adherence to physician orders for compression stockings for both residents highlights a deficiency in the facility's care practices.
Failure to Implement Hand Splint Program for Resident
Penalty
Summary
The facility failed to implement an occupational therapy (OT) ordered hand splint program for a resident, identified as R14, who was reviewed for positioning and mobility. R14 had a history of hemiplegia affecting the right dominant side and required extensive assistance for bed mobility. The care plan indicated the need for a splint to prevent contractures and manage pain, but the resident reported discomfort with the splint, leading to its non-use. Despite modifications to the splint by OT, the resident continued to experience pain, and the splint program was not consistently followed. The facility's documentation lacked evidence of the resident's refusal of the splint program and did not provide a rationale for discontinuing the splint order. Interviews with staff revealed a lack of awareness and follow-up regarding the splint program. The resident's care conferences and progress notes did not address the splint or contracture issues, and there was no documentation of discussions with the resident about the risks of not wearing the splint or options for reassessment with therapy. Observations showed the resident's right hand was contracted in a fist position, and there was an unpleasant odor, indicating potential skin issues. The facility's policy on maintaining abilities in activities of daily living was not adhered to, as the necessary care and services to prevent the resident's decline were not provided. The facility did not provide a policy on assistive devices or splint programs when requested.
Failure to Implement Fall Interventions for a Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident, identified as R40, who had a history of falls. R40's care plan indicated that the resident was at risk for falls due to osteoarthritis and required various interventions, including physical therapy, a low bed, and a clutter-free room. However, the care plan lacked specific interventions such as applying non-slip tape to the resident's room, which was noted as necessary after a fall incident. Despite the care plan's instructions, the care guide also lacked information on fall prevention interventions. R40 experienced a fall on October 3, 2024, when the resident was found on the floor after attempting to go to the bathroom independently. The interdisciplinary team reviewed the fall and planned to implement interventions such as gripper socks and non-slip tape upon the resident's return from the hospital. However, observations on subsequent days revealed that the non-slip tape was not applied to R40's room, indicating a failure to follow through with the planned interventions. Interviews with staff, including a nursing assistant and a registered nurse, confirmed that R40 was allowed to walk independently in the room and that the intervention for non-slip tape was documented but not implemented. The director of nursing acknowledged the oversight and noted that universal fall precautions were in place, but the specific intervention of non-slip tape was not executed. The facility's policy on fall prevention and management emphasized the importance of implementing fall prevention interventions, which was not adhered to in this case.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to ensure staff utilized enhanced barrier precautions (EBP) during wound care and did not follow current standards of infection control practice for catheter care for a resident identified as R30. R30 had intact cognition, stress incontinence, neurogenic bladder, two unstageable pressure injuries, and an indwelling catheter. The care plan for R30 included EBP for the foley catheter but lacked EBP for wound care. During an observation, registered nurses entered R30's room without donning the required personal protective equipment (PPE) for wound care, which was only corrected after a surveyor's intervention. Additionally, the facility did not adhere to proper infection control measures during catheter care. A nursing assistant was observed emptying a urinary catheter drainage bag without placing a barrier on the floor or using an alcohol wipe to clean the drainage outlet, as required by the facility's policy. The care plan for R30 included monitoring for signs and symptoms of urinary tract infection (UTI) but did not specify infection control measures during the emptying of the catheter. The facility's policies on EBP and indwelling catheter care were not fully implemented, as evidenced by the lack of PPE use during wound care and the absence of a barrier and alcohol wipe use during catheter care. Interviews with staff, including the director of nursing, confirmed the expectations for PPE use and infection control practices, which were not met during the observed incidents.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of hospital bed rails as part of a maintenance program, leading to a deficiency. A resident, identified as R204, who had intact cognition and required assistance with bed mobility, was observed using a bed rail that was not securely attached to the bed frame. Despite having a physician's order for bilateral grab bars to aid in bed mobility, the left bed rail was found to be loose and missing a lock during multiple observations. Nursing staff and maintenance personnel were interviewed, revealing inconsistencies in the inspection and maintenance of bed rails. While some staff claimed that bed rails were checked frequently, others admitted that they might not check all residents' bed rails regularly. The maintenance director stated that bed rails were checked daily, but he had not been informed of any issues with R204's bed rail. The administrator expected maintenance to check bed rails during rounds, but a policy or log documenting regular inspections was not provided. The only documentation available was a maintenance log indicating a bed rail inspection on a date prior to the installation of R204's bed rail. This lack of documentation and inconsistent practices contributed to the deficiency, as the facility did not ensure the safety and proper maintenance of bed rails for residents who required them.
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What surveyors actually found near you
We read the 1,040 citations issued within 25 miles in the last 12 months — including the 33 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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Louis Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jones Harrison Residence | 0.9 mi | ★★★★★ | 18 | 0 |
| The Villas At St Louis Park | 1.8 mi | ★★★★★ | 18 | 0 |
| The Villas At The Cedars | 1.8 mi | ★★★★★ | 15 | 1 |
| The Estates At St Louis Park Llc | 1.9 mi | ★★★★★ | 0 | 0 |
| Sholom Home West | 2.5 mi | ★★★★★ | 7 | 0 |
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