Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villas At St Louis Park during CMS and state inspections, most recent first.
The facility failed to maintain appropriate food temperatures, affecting two residents and potentially all 93 residents consuming food from the main kitchen. Observations revealed that hot food was served cold and cold food was served warm, with recorded temperatures not meeting facility policy. Interviews with staff confirmed the process for food delivery, but discrepancies in temperature standards were noted.
A long-term care facility was found deficient in infection control practices, including improper disinfection of a shared glucometer, failure to perform hand hygiene during perineal care, and inadequate hand hygiene between assisting residents during meals. These actions were contrary to the facility's policies and expectations, potentially leading to cross-contamination and the spread of infections.
A facility failed to create a comprehensive care plan for a resident with mood and behavior issues, lacking individualized interventions and specific target behaviors. Despite staff awareness of the resident's mood swings, paranoia, and refusal of care, the care plan did not provide specific strategies to manage these behaviors. The facility's policy required care plans to include both pharmacological and non-pharmacological interventions, which was not adequately implemented.
A resident with diabetes and dementia, who had a diabetic ulcer on the left heel, was not provided with Prevalon boots as required by their care plan. Observations revealed the resident lying in bed with bare feet, while the boots were left in a recliner. Interviews with staff confirmed the expectation for the boots to be worn to aid healing and prevent further skin breakdown, but this intervention was not implemented.
A facility failed to transcribe and follow oxygen orders for a resident with chronic respiratory conditions. Despite a care plan indicating continuous oxygen therapy at 3 liters per minute, the resident's physician orders lacked an oxygen order. Observations showed inconsistencies in oxygen administration, with staff unsure how the order disappeared from the chart, violating the facility's oxygen policy.
A facility failed to assess and identify target behaviors for a resident on psychotropic medication, impacting the evaluation of medication effectiveness. The resident exhibited mood swings, paranoia, and refusal of care, but the care plan lacked specific target behaviors. Staff interviews revealed inconsistent management of the resident's behaviors, and the director of nursing acknowledged the need for specific behavior documentation.
A facility failed to ensure a resident's call light was accessible, despite the resident being cognitively intact and dependent on staff for daily living activities. Observations found the call light out of reach, and staff confirmed the resident's ability to use it and the need for it to be within reach due to fall risk. The facility's policy required accessible call lights, highlighting a deficiency in adherence to this policy.
A resident with a stage 4 sacral pressure ulcer experienced a significant delay in scheduling an MRI, ordered to rule out osteomyelitis. The MRI was ordered on 9/3/24 but not scheduled until 10/2/24, with the appointment set for 10/21/24. The delay was due to insurance issues and lack of timely follow-up by facility staff. The DON acknowledged the failure to schedule the MRI promptly and the absence of a clear policy for imaging services.
A resident with cognitive impairments and identified as a fall and elopement risk was not provided with the required 15-minute safety checks and one-to-one staff care as outlined in their baseline care plan. This oversight led to the resident opening a facility fire door and falling outside. Staff interviews revealed communication gaps and a lack of awareness regarding the care plan requirements, resulting in the failure to implement necessary safety measures.
A resident with a history of substance use was not provided with the required written notification for discharge from the facility. Despite being cognitively intact, the resident was intoxicated and refused to sign the discharge notice. The administrator acknowledged the resident's impaired state during the notice issuance, and the resident later learned about the discharge from a hospital social worker, not from the facility as required by policy.
A resident was transferred to a hospital for detox without being informed of the bed hold policy, as required by regulations. The resident, who was cognitively intact and had a history of substance use, was not coherent enough to sign the agreement, and the facility did not contact the resident's representative. Interviews with staff confirmed the oversight, highlighting a deficiency in the facility's adherence to regulatory requirements.
The facility failed to ensure proper PPE use for residents under enhanced barrier and respiratory precautions. Staff did not wear gowns during high-contact care for a resident with a Foley catheter and another with a PICC line. Additionally, a resident on enhanced respiratory precautions had their door left open, contrary to guidelines. The facility cited insufficient PPE supplies and incomplete staff education as contributing factors.
A resident with multiple diagnoses requested to have his legs tied with a bed sheet to prevent falling off the bed. The facility failed to assess this as a potential restraint, lacked a physician's order, and did not update the care plan. Staff were unaware of the need for formal assessment, and the facility's policy on restraints was not followed.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for two residents, which had the potential to affect all 93 residents consuming food from the facility's main kitchen. The deficiency was identified through observations, interviews, and document reviews. Two residents, both with intact cognition, reported that hot food was served cold and cold food was served warm. During an observation, a test tray was requested, and the temperatures of the food items were recorded. The cold roast beef sandwich was found to be 158 degrees Fahrenheit, while the mashed potatoes, gravy, and pureed corn were 115, 129, and 113 degrees Fahrenheit, respectively. These temperatures did not meet the facility's policy requirements for food temperatures. Interviews with the dietary aide and culinary director revealed that the process involved plating the food, covering it, and placing it on a tray for delivery to residents' rooms. The dietary aide and culinary director both stated that hot food should be held at a minimum of 135 degrees Fahrenheit, and cold food should be served no warmer than 41 degrees Fahrenheit. However, the facility's policy indicated that cold food should be at or below 50 degrees Fahrenheit and hot food at or above 140 degrees Fahrenheit. The discrepancy between the observed food temperatures and the facility's policy highlights the deficiency in maintaining appropriate food temperatures for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by multiple deficiencies observed during a survey. One significant issue involved the improper disinfection of a shared glucometer after use on a resident with diabetes mellitus. The LPN responsible for checking the resident's blood sugar did not disinfect the glucometer before placing it back in a bin with clean supplies, citing being rushed as the reason for the oversight. This practice was contrary to the facility's expectations and policies, which required disinfection to prevent the spread of bloodborne pathogens. Another deficiency was observed during perineal care for two residents. Nursing assistants failed to perform hand hygiene after removing soiled gloves and before donning clean gloves while assisting residents with incontinence care. This included tasks such as tucking in clean linens and adjusting incontinence products without changing gloves or washing hands, leading to potential cross-contamination. Interviews with staff and clinical managers confirmed that the expected protocol was not followed, which required hand hygiene between dirty and clean tasks. Additionally, the facility did not ensure hand hygiene was performed by staff between assisting multiple residents during meal service in the dining area. An LPN assisted several residents with eating without washing hands between residents, despite handling utensils and wiping residents' mouths. The facility's policy required hand hygiene to prevent cross-contamination, but the LPN did not adhere to these guidelines, believing it was unnecessary since they did not touch the food directly. Interviews with clinical managers and the DON highlighted the expectation for staff to perform hand hygiene between assisting different residents to maintain sanitary practices.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident (R32) with mood and behavior issues. R32's care plan lacked individualized interventions and specific target behaviors to monitor the effectiveness of interventions. Despite being cognitively intact and having no documented behaviors or rejection of care upon admission, R32 exhibited mood swings, paranoia, and refusal of care, including eating and taking medications. The care plan directed staff to document mood states and behaviors as they occurred and to provide emotional support and comfort measures as needed. However, it did not include specific strategies tailored to R32's needs or behaviors. Interviews with staff revealed a lack of awareness and specific strategies to manage R32's behaviors. Nursing assistants and LPNs reported R32's behaviors, such as hallucinations and refusal of meals, but were not provided with specific interventions to address these issues. The social worker was not informed of R32's recent refusals and behaviors, and the clinical managers noted that target behaviors were entered into the medication or treatment administration record but did not align with the care plan. The facility's policy required care plans to reflect both pharmacological and individualized non-pharmacological interventions, along with monitoring for efficacy, which was not adequately implemented for R32.
Failure to Apply Prevalon Boots for Resident with Diabetic Ulcer
Penalty
Summary
The facility failed to ensure that Prevalon boots were applied to both feet of a resident, identified as R44, who was reviewed for non-pressure skin conditions. R44, who was cognitively impaired and diagnosed with diabetes mellitus and dementia, had a diabetic ulcer on the left heel. The care plan, revised on 12/10/24, required Prevalon boots to be worn on both heels while the resident was in bed. However, during multiple observations on 1/6/25 and 1/7/25, R44 was found lying in bed with bare feet resting directly on the mattress, and the boots were observed lying in a recliner across the room. Interviews with nursing staff, including a nursing assistant, nurse manager, nurse practitioner, and the director of nursing, confirmed that the expectation was for R44 to have the boots on while in bed to aid in healing the current wound and prevent further skin breakdown. The facility's policy on skin assessment and wound management, revised in 7/18, indicated that staff should update care plans and implement interventions when a significant alteration in skin is noted. Despite these guidelines, the necessary intervention of applying Prevalon boots was not followed, leading to the deficiency.
Failure to Transcribe and Follow Oxygen Orders
Penalty
Summary
The facility failed to transcribe and follow an oxygen order for a resident, identified as R17, who was reviewed for oxygen use. R17 had intact cognition and required assistance with activities of daily living due to conditions such as heart failure, asthma, and chronic respiratory failure. Despite having a care plan that included continuous oxygen therapy at 3 liters per minute via nasal cannula, R17's physician orders lacked an order for oxygen use. The discharge orders from a previous hospital stay indicated the need for continuous oxygen at 3 liters, but this was not reflected in the facility's records. Observations and interviews revealed inconsistencies in the administration of oxygen to R17. On one occasion, R17 was observed receiving oxygen at 3 liters per minute, while on another, the oxygen was set at 2.5 liters per minute, contrary to the care plan and discharge orders. Staff members, including LPNs and the Director of Nursing, were unsure how the oxygen order disappeared from the chart, and the facility's oxygen policy required a physician order for oxygen management. This deficiency highlights a failure in maintaining accurate and consistent medical orders for oxygen therapy, which is crucial for the resident's respiratory care.
Failure to Assess and Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to comprehensively assess and identify target behaviors to determine the effectiveness of psychotropic medication for a resident reviewed for mood and/or behavior. The resident, who was cognitively intact and required assistance with certain activities, was noted to have an alteration in mood and behavior. The care plan directed staff to document mood states and behaviors, provide emotional support, and conduct assessments as needed. However, the care plan did not identify specific target behaviors to be monitored, which is crucial for evaluating the effectiveness of psychotropic medications. The resident's physician orders included targeted behaviors such as dry mouth, agitation, headaches, and abnormal involuntary movements, with directions to chart non-pharmacological interventions and their outcomes. Despite these orders, the medication administration record showed the resident was prescribed Haloperidol for agitation, but there was no comprehensive assessment of the target behaviors. Progress notes indicated multiple instances of the resident refusing care, treatments, and medications, as well as displaying behaviors such as throwing drinks and food on the floor. Interviews with staff revealed a lack of awareness and specific strategies to address the resident's behaviors. Nursing assistants and LPNs described the resident's mood swings, paranoia, and refusal of meals and medications, but there was no consistent approach to managing these behaviors. The social worker was not aware of the resident's recent refusals and behaviors, and clinical managers stated they monitored target behaviors based on medication side effects rather than specific behavioral changes. The director of nursing acknowledged that the target behaviors listed were medication side effects and agreed that specific behaviors like delusions or hallucinations should be documented to monitor the effectiveness of psychotropic medications.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was reviewed for call light accessibility. The resident, who was cognitively intact and had diagnoses of anxiety and depression, was dependent on staff for activities of daily living and mobility. The resident's care plan included an intervention to ensure the call light was within reach and answered promptly, as this helped reassure the resident. However, during observations, the call light was found on the floor under the bed and attached to the bed rail, both times out of the resident's reach. The resident expressed that the call light was often left out of reach, and staff confirmed that the resident was able to use the call light and was a fall risk, necessitating the call light to be within reach. Interviews with staff, including a nursing assistant, nurse manager, and director of nursing, verified that the call light was not within reach of the resident, despite the expectation that it should be. The facility's policy required that residents have a means of directly contacting caregivers when in their rooms, and the system should be functioning properly. The failure to ensure the call light was accessible to the resident represents a deficiency in the facility's adherence to its policy and the care plan for the resident.
Delayed MRI Scheduling for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely follow-up on ordered radiologic studies for a resident with a stage 4 sacral pressure ulcer, which included exposed bone. The nurse practitioner (NP) ordered an MRI on 9/3/24 to rule out osteomyelitis, a bone infection, due to the severity of the wound. Despite the urgency, the MRI was not scheduled until 10/2/24, with the appointment set for 10/21/24. The delay in scheduling the MRI was attributed to issues with the resident's insurance and a lack of timely follow-up by the facility staff. The health information assistant (HIA) was responsible for scheduling the MRI but did not become aware of the order until 9/26/24, nearly three weeks after it was placed. The HIA cited difficulties with the resident's insurance as a reason for the delay. The nurse practitioner expressed concern over the prolonged scheduling process, noting that attempts to schedule the MRI should have been made within two weeks of the order. The director of nursing (DON) confirmed that the MRI was not scheduled in a timely manner and acknowledged that the facility lacked a clear policy for imaging and diagnostic services. The DON stated that the MRI should have been scheduled by early September, shortly after the order was placed. The facility's failure to ensure timely scheduling of the MRI did not meet the expectations for executing physician orders promptly, as outlined in their policy.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to implement the baseline care plan for a resident who was admitted with cognitive concerns and was identified as a fall and elopement risk. The resident's care plan required 15-minute safety checks and one-to-one staff care, which were not implemented. As a result, the resident, who was severely cognitively impaired with a BIMS score of 5 and diagnosed with encephalopathy and aphasia, managed to open a facility fire door while seated in a wheelchair and fell outside onto the concrete. This incident occurred because the safety measures outlined in the care plan were not followed. Interviews with staff revealed a lack of communication and implementation of the care plan. The registered nurse who admitted the resident reported the elopement and fall risk to the nurse manager, but the nurse manager did not recall this information. The nursing assistants were not aware of the 15-minute safety checks or one-to-one care requirements, as these were not reflected in their daily assignment sheets. The director of nursing confirmed that no safety checks were documented, and the interventions on the care plan were autogenerated and not intended to be implemented until the comprehensive care plan was completed.
Failure to Provide Written Notification for Resident Discharge
Penalty
Summary
The facility failed to provide the required written notifications for transfers to a resident and/or their representative, as evidenced by the case of a resident who was cognitively intact and had a history of substance use. The resident was independent in activities of daily living and had diagnoses including seizures, anxiety, and depression. On multiple occasions, the resident returned to the facility visibly intoxicated, which led to interactions with staff regarding their alcohol use and subsequent decisions about their care. On one particular day, the resident returned to the facility intoxicated, and staff noted the smell of alcohol and the resident's difficulty in focusing. The resident was issued a 30-day notice of discharge due to no longer requiring skilled nursing facility care, but refused to sign the notice. The administrator explained the appeal process and provided the resident with a copy of the notice, which was also mailed to the ombudsman office. However, the resident's medical record lacked documentation that the resident or their representative received a written notification of discharge. The administrator later acknowledged that the resident was very impaired when the discharge was discussed and given, and admitted that the resident might not have understood the discharge notice. The resident confirmed that they were not given a 30-day written notice before being sent to the emergency room for detoxification. Instead, the resident learned about the discharge from a social worker at the hospital. The facility's policy required written notification in a language and format understood by the resident or their representative at least 30 days prior to a facility-initiated discharge, which was not adhered to in this case.
Failure to Inform Resident of Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to inform a resident or their representative about the bed hold policy during a hospital transfer, which is a requirement under 42 CFR S483.15(c)(4)(ii)(D). The resident, who was cognitively intact and had a history of substance use, was sent to the hospital for detox after appearing intoxicated upon returning from a leave of absence. The facility's progress notes indicated that the resident was not coherent enough to sign a bed hold agreement, and the facility did not reach out to the resident's family or legal representative to provide the necessary information. Interviews with the facility's administrator and director of nursing revealed that the bed hold policy was not communicated due to the resident's impaired state. The facility's policy requires that a notice of transfer and bed hold information be provided to the resident or their representative as soon as practicable before a transfer. However, the resident reported not being aware of the bed hold policy and did not receive any form to sign. The facility's failure to provide this information constitutes a deficiency in adhering to regulatory requirements.
Inadequate PPE Use and Precaution Implementation
Penalty
Summary
The facility failed to ensure appropriate donning and doffing of personal protective equipment (PPE) for residents under enhanced barrier precautions (EBP) and enhanced respiratory precautions. For Resident 3, who had a Foley catheter and required extensive assistance with activities of daily living, staff were observed not wearing gowns while performing high-contact care activities such as dressing and transferring. Nursing assistants involved in the care of Resident 3 were unaware that gowns were required, indicating a lack of proper training or communication regarding PPE protocols. Resident 26, who had a peripherally inserted central catheter (PICC) and a wound vacuum-assisted closure device, also did not receive care with the appropriate PPE. A registered nurse was observed administering intravenous medication without wearing a gown, contrary to the expectations for EBP. The resident confirmed that not all staff adhered to the gown and glove requirements during care, highlighting inconsistencies in the implementation of infection control measures. For Resident 31, who was on enhanced respiratory precautions due to pneumonia, the facility failed to keep the resident's door closed as required. Observations noted the door was open on multiple occasions, and the infection preventionist confirmed that the facility had not fully implemented the plan for enhanced respiratory precautions. The facility's infection preventionist and director of nursing acknowledged the lack of PPE supplies and incomplete staff education as contributing factors to these deficiencies.
Failure to Assess and Document Use of Restraint
Penalty
Summary
The facility failed to comprehensively assess the use of a restrictive device, specifically a bed sheet tied around a resident's legs, as a potential restraint. The resident, who had intact cognition and multiple diagnoses including hypertension, heart failure, and anxiety disorder, required substantial assistance for activities of daily living. Despite the resident's request to have his legs tied to prevent falling off the bed, there was no evidence of a restraint assessment, physician's order, or updated care plan to justify the use of the bed sheet as a restraint. Observations confirmed that the resident was unable to move his legs out of the knotted sheet, indicating it functioned as a restraint. Interviews with staff revealed that the resident directed his own care and requested the use of the bed sheet to secure his legs. However, staff members, including a registered nurse, a nurse aide, and a licensed practical nurse, were unaware of the need for a formal assessment or physician's order for this intervention. The assistant director of nursing and the director of nursing were also not informed of the practice, and no assessments or recommendations were completed prior to implementing the restraint. The facility's policy on residents' rights emphasized the need for the least restrictive alternatives and ongoing re-evaluation of restraints, which was not adhered to in this case.
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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 Saint Louis Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villas At The Cedars | 0.7 mi | — | 9 | 1 |
| The Estates At St Louis Park Llc | 1.2 mi | — | 0 | 0 |
| The Villas At Brookview | 1.6 mi | — | 25 | 1 |
| The Villas At The Park | 1.8 mi | — | 11 | 0 |
| Sholom Home West | 1.8 mi | — | 7 | 0 |
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