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Public Record

Villas At Bryn Mawr LLC

Nursing HomeMinneapolis, MNCMS 245203
61 citations on record

Operated by Monarch Healthcare Management

From CMS

Facility profile

CMS overall rating
1 / 5

*CMS Five-Star

Certified beds
105

*CMS

Avg. residents per day
99.3

*CMS

Inspection record

On record from CMS

Health citations
61

*CMS

Fire safety findings
23

*CMS

Inspections on file
16

*CMS

Last inspection
2026-03-13

*CMS

Citations

61 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0684Seriousimmediate jeopardy

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

  • 0692Generalpotential for harm

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

  • 0686Seriousactual harm

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

  • 0600Seriousimmediate jeopardy

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

  • 0578Seriousimmediate jeopardy

    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.

  • 0742Generalpotential for harm

    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.

  • 0609Generalpotential for harm

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

  • 0755Generalpotential for harm

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

  • 0657Generalpotential for harm

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

  • 0689Seriousimmediate jeopardy

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

  • 0692Generalpotential for harm

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

  • 0684Generalpotential for harm

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

  • 0576Generalpotential for harm

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

  • 0583Generalno actual harm

    Keep residents' personal and medical records private and confidential.

  • 0638Generalpotential for harm

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

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0676Generalpotential for harm

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

  • 0677Generalpotential for harm

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

  • 0685Generalpotential for harm

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

  • 0687Generalpotential for harm

    Provide appropriate foot care.

  • 0688Generalpotential for harm

    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.

  • 0740Generalpotential for harm

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

  • 0758Generalpotential for harm

    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.

  • 0812Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0921Generalpotential for harm

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

  • 0755Generalpotential for harm

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

  • 0684Generalpotential for harm

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

  • 0949Generalpotential for harm

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

  • 0914Generalpotential for harm

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

  • 0944Generalno actual harm

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

  • 0689Seriousimmediate jeopardy

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

  • 0941Generalno actual harm

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

  • 0812Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0883Generalpotential for harm

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

  • 0554Generalpotential for harm

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

  • 0584Generalpotential for harm

    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.

  • 0677Generalpotential for harm

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

  • 0693Generalpotential for harm

    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.

  • 0699Generalpotential for harm

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

  • 0732Generalno actual harm

    Post nurse staffing information every day.

  • 0686Generalpotential for harm

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

  • 0758Generalpotential for harm

    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.

  • 0553Generalpotential for harm

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

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0580Generalpotential for harm

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

  • 0609Generalpotential for harm

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

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0655Generalpotential for harm

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

  • 0656Generalpotential for harm

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

  • 0658Generalpotential for harm

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

  • 0677Generalpotential for harm

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

  • 0684Generalpotential for harm

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

  • 0689Generalpotential for harm

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

  • 0691Generalpotential for harm

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

  • 0742Generalpotential for harm

    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.

  • 0755Generalpotential for harm

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

  • 0757Generalpotential for harm

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

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0921Generalpotential for harm

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

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

Showing the 10 most recent inspections. 6 earlier inspections are also on record.

Ownership

Monarch Healthcare Management

45nursing homes nationwide, in CMS records

See the full ownership footprint

FAQ

Questions and answers

What is Villas At Bryn Mawr LLC?
Villas At Bryn Mawr LLC is a Medicare- and Medicaid-certified nursing home in Minneapolis, MN, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 245203.
What is the CMS rating for Villas At Bryn Mawr LLC?
Villas At Bryn Mawr LLC has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Villas At Bryn Mawr LLC have?
Villas At Bryn Mawr LLC is certified for 105 beds. It serves an average of 99.3 residents per day.
How many citations does Villas At Bryn Mawr LLC have?
Villas At Bryn Mawr LLC has 61 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Villas At Bryn Mawr LLC last inspected?
Villas At Bryn Mawr LLC was last inspected on March 13, 2026. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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