Federal Nursing-Home Survey Record
Villas At Bryn Mawr LLC
Does Villas At Bryn Mawr LLC have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Villas At Bryn Mawr LLC (CCN 245203), in MINNEAPOLIS, MN, has federal inspection findings on its record. CMS currently displays its federal abuse icon for this facility — a flag CMS assigns under its own published methodology for abuse-related citations (deficiency tag F600 and related). CMS also lists the facility as a candidate for its Special Focus Facility program; a candidate is not on the active watch list.
In its current inspection cycle, CMS cited the facility for 25 deficiencies; the most serious carries scope/severity J on CMS's A–L scale, a level CMS classifies as Immediate Jeopardy. The most recent federal survey on file is dated 2025-03-27. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $35,260 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own.
The Federal Record
CMS has flagged this facility with its federal abuse icon.
Below is this facility's federal survey record as on file with CMS.
Federal abuse icon on file
CMS displays its abuse icon for facilities it has cited for resident abuse under its own published methodology (deficiency tag F600 and related). This is the government's own flag, restated here.
A candidate for the federal Special Focus Facility watch list
CMS lists this facility as a candidate for the Special Focus Facility program. It is not on the active watch list.
Scope & Severity — current cycle
Civil money penalties on file
$35,260
CMS has $35,260 in civil money penalties on file against this facility.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.2
Deficiency timeline — full federal history
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide enough food/fluids to maintain a resident's health.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Honor 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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide 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.
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.
Ensure 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.
Provide and implement an infection prevention and control program.
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.
Ensure each resident must receive and the facility must provide necessary behavioral health care and 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.
Keep residents' personal and medical records private and confidential.
35 citations from earlier inspection cycles — historical, not current (expand)
Provide enough food/fluids to maintain a resident's health.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Develop, 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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
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.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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.
Allow residents to self-administer drugs if determined clinically appropriate.
Provide care or services that was trauma informed and/or culturally competent.
Post nurse staffing information every day.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
PASARR screening for Mental disorders or Intellectual Disabilities
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Reasonably accommodate the needs and preferences of each resident.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 appropriate treatment and care according to orders, resident’s preferences and goals.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Document what happened
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