The Villas at New Brighton

In the surveyor’s words

From the most serious findings on record at The Villas at New Brighton, in the surveyor’s own words.

• Immediate jeopardy, patternF602Feb 11, 2025

  Based on interview and document review, the facility failed to ensure a system was in place to prevent the diversion of medications for 30 of 79 residents (R1, R5, R12, R15, R16, R27, R35, R41, R49, R50, R54, R58, R63, R73, R75, R76, R77, R141, R146, R149, R345, R25, R143, R144, R145, R147, R148, R150, and R151) reviewed for drug diversion and were free from misappropriation of their property when their medications to treat moderate to severe pain and other conditions were taken by a staff member. […]

• Immediate jeopardy, isolatedF689Sep 10, 2025

  Based on interview and document review, the facility failed to ensure safe transfers with a full body mechanical lift. This resulted in an immediate jeopardy (IJ) for 1 of 4 residents (R1) who sustained a left femur fracture due to a fall from a lift. The immediate jeopardy (IJ) began on 8/29/25, when R1 fell out of a full mechanical lift sling that was not attached to the lift according to manufacturer instructions resulting in a fall with fracture for R1. The administrator and director of nursing (DON) were notified of the IJ on 9/10/25 at 1:49 p.m. […]

• Immediate jeopardy, isolatedF686Apr 15, 2025

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

• Immediate jeopardy, isolatedF689Apr 8, 2025

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

• Immediate jeopardy, isolatedF678Aug 1, 2024

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