The Villas at Robbinsdale

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 17, 2026

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

• Immediate jeopardy, isolatedF880Aug 25, 2023

  Based on observation, interview and document review, the facility failed to implement all suggested mitigation efforts based on Centers for Disease Control (CDC) and Minnesota Department of Health (MDH) recommended guidelines to ensure prevention, and minimize the transmission of Klebsiella pneumoniae carbapenemase (KPC) producing carbapenem-resistant Enterobacterales (CRE). KPC producing CRE is a type of bacteria that can cause serious infections that can be hard to treat; most often spread person-to-person in healthcare settings specifically through contact with the infected or colonized people through contact with wounds or stool. The facility had seven residents with active KPC-producing CRE. […]

• Immediate jeopardy, isolatedF880Jul 14, 2022

  Based on observation, interview and document review, the facility failed to ensure Centers for Disease Control (CDC) transmission based precautions guidelines were followed to prevent and minimize the transmission of carbapenem-resistant Enterobacterales (CRE-type of bacteria that can cause serious infections that can be hard to treat; most often spread person-to-person in healthcare settings specifically through contact with the infected or colonized people through contact with wounds or stool) for 3 of 3 residents (R1, R2, R3) who remained in the building and R5 and R6 who discharged from the facility that had confirmed or history of CRE results; failed to ensure proper hand hygiene and glove use to prevent the spread of CRE for 2 of 2 residents (R1, R2); failed to ensure education was… […]

• Actual harm, isolatedF690Jun 2, 2023

  Based on interview and document review, the facility failed to provide follow-up appointments with a urologist for 1 of 3 residents (R1) reviewed for indwelling catheter use. This resulted in actual harm to R1 when he developed a urinary tract infection (UTI), became septic, and was hospitalized . Findings include: R1's Admission Record dated 11/14/22, indicated R1's diagnoses included neuromuscular dysfunction of bladder, and type 2 diabetes mellitus. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had neuromuscular dysfunction of bladder. The MDS also indicated R1 had an indwelling Foley catheter, required total assistance for transfers and toileting, and was cognitively intact. R1's care plan initiated 11/14/22, indicated R1 had neuromuscular dysfunction of bladder. […]

• Actual harm, isolatedF684Dec 30, 2021

  Based on observation, interview, and document review, the facility failed to implement interventions to prevent the worsening of open areas on the skin, as well as the development of new open areas for 1 of 3 residents (R1) reviewed for skin breakdown. This resulted in actual harm to R1 when he sustained moisture associated skin damage (MASD, damage to skin when it is in contact to moisture for too long) breakdown on his buttocks that worsened, and developed two new areas of MASD breakdown. Findings include: R1's Face Sheet printed on 12/30/21, indicated R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Braden Scale (skin risk assessment) dated 12/1/21, indicated R1's was at low risk for skin breakdown. […]