Villas At Bryn Mawr LLC
275 Penn Avenue North, Minneapolis, MN 554056123774723105 certified beds · 97 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
13
since 2024
Deficiencies
57
● 4● 47● 6
Penalties · 3 yrs
$51,980
2 fines
Last survey
2026-06-17
Standard
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 4
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Minnesota Department of Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-06-17 | Standard | 0140 | CMS-2567 (Care Compare) | — |
| 2026-03-13 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2026-02-27 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2025-09-29 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2025-09-11 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2025-06-24 | Complaint | 041 | CMS-2567 (Care Compare) | — |
| 2025-04-15 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-03-27 | Standard | 1140 | CMS-2567 (Care Compare) | — |
| 2025-01-23 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-01-14 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-08-12 | Complaint | 221 | CMS-2567 (Care Compare) | — |
| 2024-05-02 | Standard | 180 | CMS-2567 (Care Compare) | — |
| 2024-02-26 | Complaint | 010 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Minnesota Department of Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F550
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F582
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F584
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F605
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F609
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F628
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F641
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F657
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F684
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F761
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F880
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F919
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F921
F924Put firmly secured handrails on each side of hallways.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-29Record 245203-20260617-F924
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2026-04-07Record 245203-20260313-F684
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-07Record 245203-20260313-F692
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Correction not yet recordedRecord 245203-20260227-F686
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-10-15Record 245203-20250929-F600
F578Honor 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.Scope/severity JHarm
Dignity & rights
Isolated; immediate jeopardy to resident health or safety.Correction not yet recordedRecord 245203-20250911-F578
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-06-10Record 245203-20250624-F689
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-18Record 245203-20250624-F609
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-18Record 245203-20250624-F657
F742Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-18Record 245203-20250624-F742
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-18Record 245203-20250624-F755
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250415-F692
F576Ensure residents have reasonable access to and privacy in their use of communication methods.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F576
F638Assure that each resident’s assessment is updated at least once every 3 months.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F638
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F645
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F676
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F684
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F685
F687Provide appropriate foot care.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F687
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F688
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F740
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F758
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F812
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F880
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-29Record 245203-20250327-F921
F583Keep residents' personal and medical records private and confidential.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2025-04-29Record 245203-20250327-F583
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-14Record 245203-20250123-F755
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-03Record 245203-20250114-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity LHarm
Care planningFalls
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-09-04Record 245203-20240812-F689
F914Provide bedrooms that don't allow residents to see each other when privacy is needed.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-04Record 245203-20240812-F914
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-04Record 245203-20240812-F949
F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Scope/severity BPaperwork
Records
Pattern; potential for minimal harm.Corrected 2024-09-04Record 245203-20240812-F941
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity BPaperwork
Records
Pattern; potential for minimal harm.Corrected 2024-09-04Record 245203-20240812-F944
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F554
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F584
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F677
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F693
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F699
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-14Record 245203-20240502-F883
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2024-06-14Record 245203-20240502-F732
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-08Record 245203-20240226-F686
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2026-02-27 | Civil money penalty | $16,720 | CMS · Penalties |
| 2024-08-12 | Civil money penalty | $35,260 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.68
Facility
Minnesota
National
Minnesota 1.06 · National 0.69
Total nurse hours per resident day2.73
Facility
Minnesota
National
Minnesota 4.19 · National 3.86
Weekend total nurse hours2.54
Facility
Minnesota
National
Minnesota 3.71 · National 3.42
Total nursing staff turnover29%
Facility
Minnesota
National
Minnesota 42% · National 46%
Registered nurse turnover46%
Facility
Minnesota
National
Minnesota 39% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Minnesota | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 2.1% | 5.2% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 2.5% | 4.0% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 23.3% | 17.1% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.8% | 2.6% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 5.6% | 18.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 2.1% | 4.1% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 12.3% | 12.5% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Monarch Healthcare Operating Xii LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Halpert, Marc Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Jaffa, Noam Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Legum, Joshua Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Nij LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Spartan Healthcare LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Stern, William Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Wbs Holdings LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Yazoma Holdings, LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Halpert, Marc Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Halpert, Marc Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Jaffa, Noam Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Legum, Joshua Individual | CONTRACTED MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
| Stern, William Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
Part of a chain
Monarch Healthcare Management — 45 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Minnesota.
No county cost figures on file for Hennepin.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Courage Kenny Rehabilitation Institutes Trp Golden Valley | 1.7 mi | 2026-07-02 | 381 |
| Southside Care Center Minneapolis | 1.9 mi | 2026-04-06 | 2582 |
| Jones Harrison Residence Minneapolis | 2.0 mi | 2026-07-02 | 1281 |
| The Estates At Chateau LLC Minneapolis | 2.1 mi | 2026-05-14 | 2471 |
| Birchwood Care Home Minneapolis | 2.5 mi | 2026-05-19 | 2281 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |