VILLAS AT BRYN MAWR LLC

Special Focus Facility candidate · CMS abuse icon · CCN 245203 · VILLAS AT BRYN MAWR LLC · For profit - Corporation · MONARCH HEALTHCARE MANAGEMENT chain · 105 certified beds · Hennepin · MN


VILLAS AT BRYN MAWR LLC is a 105-bed nursing home in MINNEAPOLIS, Minnesota. CMS has certified it for Medicare and Medicaid since 1978-10-01. It averages 97.2 residents a day.

What harm was found in the violations cited at VILLAS AT BRYN MAWR LLC?

CMS lists 57 health-inspection deficiencies for VILLAS AT BRYN MAWR LLC, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is L; the most recent health inspection was 2026-06-17.

Survey dateTagDeficiencySeverity
2026-06-17F0609, F0921, F0924Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. / Put firmly secured handrails on each side of hallways.E
2026-06-17F0550, F0582, F0584, F0605, F0628, F0641, F0657, F0684, F0761, F0880, F0919Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. / Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. / Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. / Ensure each resident receives an accurate assessment. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. / Provide and implement an infection prevention and control program. / Make sure that a working call system is available in each resident's bathroom and bathing area.D
2026-03-13F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.J
2026-03-13F0692Provide enough food/fluids to maintain a resident's health.D
2026-02-27F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.G
2025-09-29F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.J
2025-09-11F0578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.J
2025-06-24F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J
2025-06-24F0609, F0657, F0742, F0755Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D
2025-04-15F0692Provide enough food/fluids to maintain a resident's health.D
2025-03-27F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2025-03-27F0684, F0921Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.E
2025-03-27F0576, F0638, F0645, F0676, F0677, F0685, F0687, F0688, F0740, F0758, F0880Ensure residents have reasonable access to and privacy in their use of communication methods. / Assure that each resident’s assessment is updated at least once every 3 months. / PASARR screening for Mental disorders or Intellectual Disabilities / Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Assist a resident in gaining access to vision and hearing services. / Provide appropriate foot care. / Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. / Ensure each resident must receive and the facility must provide necessary behavioral health care and services. / Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. / Provide and implement an infection prevention and control program.D
2025-03-27F0583Keep residents' personal and medical records private and confidential.B
2025-01-23F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D
2025-01-14F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D
2024-08-12F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.L
2024-08-12F0914, F0949Provide bedrooms that don't allow residents to see each other when privacy is needed. / Provide behavior health training consistent with the requirements and as determined by a facility assessment.D
2024-08-12F0941, F0944Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.B
2024-05-02F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2024-05-02F0880Provide and implement an infection prevention and control program.E
2024-05-02F0554, F0584, F0677, F0693, F0699, F0883Allow residents to self-administer drugs if determined clinically appropriate. / Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. / Provide care or services that was trauma informed and/or culturally competent. / Develop and implement policies and procedures for flu and pneumonia vaccinations.D
2024-05-02F0732Post nurse staffing information every day.C
2024-02-26F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.D

Why was VILLAS AT BRYN MAWR LLC fined 2 times?

DateTypeAmount
2026-02-27Fine$16,720
2024-08-12Fine$35,260

How is VILLAS AT BRYN MAWR LLC staffed relative to the MN average?

MeasureThis facilityMN average
Total nurse staffing hours per resident per day2.734184.19318
Total nursing staff turnover (%)29.242.2
Average number of residents per day97.260.3

Who owns VILLAS AT BRYN MAWR LLC, and what chain is it in?

VILLAS AT BRYN MAWR LLC is registered with CMS as For profit - Corporation, operates under the legal business name VILLAS AT BRYN MAWR LLC and belongs to the MONARCH HEALTHCARE MANAGEMENT chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTMONARCH HEALTHCARE OPERATING XII LLCsince 01/01/2023
5% OR GREATER INDIRECT OWNERSHIP INTERESTNIJ LLC, SPARTAN HEALTHCARE LLC, WBS HOLDINGS LLC, YAZOMA HOLDINGS, LLC, HALPERT, MARC, JAFFA, NOAM, LEGUM, JOSHUA, STERN, WILLIAMsince 01/01/2023
CONTRACTED MANAGING EMPLOYEELEGUM, JOSHUAsince 01/01/2023
CORPORATE DIRECTORJAFFA, NOAMsince 01/01/2023
CORPORATE OFFICERHALPERT, MARC, STERN, WILLIAMsince 01/01/2023
OPERATIONAL/MANAGERIAL CONTROLHALPERT, MARCsince 01/01/2023

Were you or a family member harmed at VILLAS AT BRYN MAWR LLC?