The Villas At Bryn Mawr LLC
275 PENN AVENUE NORTH, MINNEAPOLIS, MN 55405 · CCN 245203
SFF Candidate Abuse icon
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★★★☆ 4
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 105
- Avg residents/day
- 102.8
- Phone
- 6123774723
Inspection history vs Minnesota & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Minnesota avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-03-27 | 23 | 8.1 | 9.5 | +14.9 worse |
| 2 | 2024-05-02 | 16 | 7.8 | 9.8 | +8.2 worse |
| 3 | 2023-03-09 | 19 | 7.4 | 9.3 | +11.6 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 2 |
| Quality of life and care | 10 |
| Resident assessment and care planning | 3 |
| Resident rights | 3 |
| Nutrition and dietary | 1 |
| Pharmacy service | 2 |
| Environmental | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.69 | 29.5% |
| RN staffing (reported) | 0.66 | 40.0% |
| Total nurse staffing (adjusted) | 3.91 | — |
Fines & penalties
- Total fines
- $35,260
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- MONARCH HEALTHCARE MANAGEMENT
- Facilities in chain
- 45
- Chain avg overall
- 2.30 / 5
Inspection citations (58)4 immediate jeopardy
- JF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-09-29 · Health · corrected 2025-10-15
Immediate jeopardy
- JF0578Honor 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.2025-09-11 · Health
Immediate jeopardy
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-06-24 · Health · corrected 2025-07-18
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-06-24 · Health · corrected 2025-07-18
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-06-24 · Health · corrected 2025-06-10
Immediate jeopardy
- DF0742Provide 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.2025-06-24 · Health · corrected 2025-07-18
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-06-24 · Health · corrected 2025-07-18
Potential for more than minimal harm
- DF0692Provide enough food/fluids to maintain a resident's health.2025-04-15 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0576Ensure residents have reasonable access to and privacy in their use of communication methods.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- BF0583Keep residents' personal and medical records private and confidential.2025-03-27 · Health · corrected 2025-04-29
Potential for minimal harm
- DF0638Assure that each resident’s assessment is updated at least once every 3 months.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0645PASARR screening for Mental disorders or Intellectual Disabilities2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0685Assist a resident in gaining access to vision and hearing services.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0687Provide appropriate foot care.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0688Provide 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.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0758Implement 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.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- EF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2025-03-27 · Health · corrected 2025-04-29
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-01-23 · Health · corrected 2025-02-14
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-01-14 · Health · corrected 2025-02-03
Potential for more than minimal harm
- LF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-08-12 · Health · corrected 2024-09-04
Immediate jeopardy
- DF0914Provide bedrooms that don't allow residents to see each other when privacy is needed.2024-08-12 · Health · corrected 2024-09-04
Potential for more than minimal harm
- BF0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.2024-08-12 · Health · corrected 2024-09-04
Potential for minimal harm
- BF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2024-08-12 · Health · corrected 2024-09-04
Potential for minimal harm
- DF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2024-08-12 · Health · corrected 2024-09-04
Potential for more than minimal harm
- DF0554Allow residents to self-administer drugs if determined clinically appropriate.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- DF0584Honor 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.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- DF0693Ensure 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.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- DF0699Provide care or services that was trauma informed and/or culturally competent.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- CF0732Post nurse staffing information every day.2024-05-02 · Health · corrected 2024-06-14
Potential for minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2024-05-02 · Health · corrected 2024-06-14
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-02-26 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- EF0645PASARR screening for Mental disorders or Intellectual Disabilities2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0742Provide 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.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0758Implement 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.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
- FF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2023-03-09 · Health · corrected 2023-05-03
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| MONARCH HEALTHCARE OPERATING XII LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2023-01-01 |
| NIJ LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| SPARTAN HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| WBS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| YAZOMA HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| HALPERT, MARC | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| JAFFA, NOAM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| LEGUM, JOSHUA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| STERN, WILLIAM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2023-01-01 |
| HALPERT, MARC | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-01-01 |
| JAFFA, NOAM | Individual | CORPORATE DIRECTOR | — | 2023-01-01 |
| HALPERT, MARC | Individual | CORPORATE OFFICER | — | 2023-01-01 |
| STERN, WILLIAM | Individual | CORPORATE OFFICER | — | 2023-01-01 |
| LEGUM, JOSHUA | Individual | CONTRACTED MANAGING EMPLOYEE | — | 2023-01-01 |
Other facilities in MINNEAPOLIS
| Name | Overall | Beds |
|---|---|---|
| Mount Olivet Home | ★★★★★ | 92 |
| Fairview University Trans Serv | ★★★★★ | 28 |
| REDEEMER RESIDENCE INC | ★★★★★ | 119 |
| Catholic Eldercare On Main | ★★★★☆ | 164 |
| Mount Olivet Careview Home | ★★★☆☆ | 155 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.