Facility Watch Inspection records for every certified US nursing home

Villas At Bryn Mawr LLC

275 Penn Avenue North
Minneapolis, MN 55405
(612) 377-4723

Special Focus Facility — SFF CandidateAbuse icon
CCN
245203
Certified beds
105
Ownership
For profit - Limited Liability company
Chain
Monarch Healthcare Management

Nurse staffing

4.04
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.91 hours per resident per day

Nursing staff turnover: 30% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected March 13, 2026

2 citations · from a complaint investigation · Health
D
F0692 No actual harm with potential for more than minimal harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected April 7, 2026 · under dispute by the facility
J
F0684 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected April 7, 2026 · under dispute by the facility

Inspected February 27, 2026

1 citation · from a complaint investigation · Health
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Past Non-Compliance

Inspected September 29, 2025

1 citation · from a complaint investigation · Health
J
F0600 Immediate jeopardy to resident health or safety · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected October 15, 2025

Inspected September 11, 2025

1 citation · from a complaint investigation · Health
J
F0578 Immediate jeopardy to resident health or safety · Isolated

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.

Past Non-Compliance

Inspected June 24, 2025

5 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected July 18, 2025
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected July 18, 2025
D
F0742 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 18, 2025
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected July 18, 2025
J
F0689 Immediate jeopardy to resident health or safety · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Past Non-Compliance · corrected June 10, 2025

Inspected April 15, 2025

1 citation · from a complaint investigation · Health
D
F0692 No actual harm with potential for more than minimal harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected April 29, 2025

Inspected March 27, 2025

15 citations · from a complaint investigation · Health
B
F0583 No actual harm with potential for minimal harm · Pattern

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0576 No actual harm with potential for more than minimal harm · Isolated

Ensure residents have reasonable access to and privacy in their use of communication methods.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0638 No actual harm with potential for more than minimal harm · Isolated

Assure that each resident’s assessment is updated at least once every 3 months.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0645 No actual harm with potential for more than minimal harm · Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0676 No actual harm with potential for more than minimal harm · Isolated

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0685 No actual harm with potential for more than minimal harm · Isolated

Assist a resident in gaining access to vision and hearing services.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0740 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected April 29, 2025
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected April 29, 2025
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected April 29, 2025
E
F0921 No actual harm with potential for more than minimal harm · Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected April 29, 2025
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected April 29, 2025

Inspected January 23, 2025

1 citation · from a complaint investigation · Health
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected February 14, 2025

Inspected January 14, 2025

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected February 3, 2025

Inspected August 12, 2024

5 citations · from a complaint investigation · Health
B
F0941 No actual harm with potential for minimal harm · Pattern

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has date of correction · corrected September 4, 2024
B
F0944 No actual harm with potential for minimal harm · Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected September 4, 2024
D
F0914 No actual harm with potential for more than minimal harm · Isolated

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Deficient, Provider has date of correction · corrected September 4, 2024
D
F0949 No actual harm with potential for more than minimal harm · Isolated

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected September 4, 2024
L
F0689 Immediate jeopardy to resident health or safety · Widespread

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected September 4, 2024

Inspected May 2, 2024

9 citations · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected June 14, 2024
D
F0554 No actual harm with potential for more than minimal harm · Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Deficient, Provider has date of correction · corrected June 14, 2024
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected June 14, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected June 14, 2024
D
F0693 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected June 14, 2024
D
F0699 No actual harm with potential for more than minimal harm · Isolated

Provide care or services that was trauma informed and/or culturally competent.

Deficient, Provider has date of correction · corrected June 14, 2024
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected June 14, 2024
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected June 14, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected June 14, 2024

Inspected February 26, 2024

1 citation · from a complaint investigation · Health
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected March 8, 2024

Inspected March 9, 2023

18 citations · Health
D
F0553 No actual harm with potential for more than minimal harm · Isolated

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0691 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0742 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 3, 2023
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected May 3, 2023
E
F0645 No actual harm with potential for more than minimal harm · Pattern

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected May 3, 2023
F
F0921 No actual harm with potential for more than minimal harm · Widespread

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected May 3, 2023

Penalties

DateTypeAmount
February 27, 2026Fine$16,720
August 12, 2024Fine$35,260

Ownership transfers

EffectiveSellerBuyer
01/01/2023Villa at Bryn Mawr LLCVillas at Bryn Mawr LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.