Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 The Park during CMS and state inspections, most recent first.
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 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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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) |
|---|---|---|---|---|
| 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 | — | 9 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.