The Villas At Bryn Mawr LLC

MINNEAPOLIS, MN · 105 beds · For profit - Limited Liability company

0 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • This facility has a substantiated finding of abuse
  • 1-star health inspection rating (lowest possible)
  • 23 deficiencies — 2.9x the state average
  • 4 citation(s) at the highest severity level — immediate risk to residents

Green Flags

  • 4-star staffing rating

Quick Facts

★☆☆☆☆
CMS Overall
★☆☆☆☆
Health Inspection
23
2.9x state avg
Deficiencies
$35,260
Fines (3-yr)
★★★★☆
Staffing

Violation Timeline

September 28, 2025

1 deficiency
F0600 Immediate Jeopardy Scope/Severity: J

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

September 10, 2025

1 deficiency
F0578 Immediate Jeopardy Scope/Severity: J

Resident Rights Deficiencies

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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.

June 23, 2025

5 deficiencyies
F0609 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

F0689 Immediate Jeopardy Scope/Severity: J

Quality of Life and Care Deficiencies

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

F0742 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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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.

F0755 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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

April 14, 2025

1 deficiency
F0692 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

March 26, 2025

12 deficiencyies
F0576 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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

F0583 No Harm Scope/Severity: B

Resident Rights Deficiencies

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Keep residents' personal and medical records private and confidential.

F0638 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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

F0645 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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PASARR screening for Mental disorders or Intellectual Disabilities

F0676 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0684 Potential Harm Scope/Severity: E

Quality of Life and Care Deficiencies

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

F0685 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0687 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate foot care.

F0688 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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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.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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

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Staffing

0.96
RN hrs/res/day
0.84
LPN hrs/res/day
2.11
CNA hrs/res/day
3.52
Weekend hrs/res/day
30%
Total nurse turnover
40%
RN turnover

A nurse checks on each resident roughly every 6.1 hours on average.

Fines & Penalties

  • Fine Aug 11, 2024
    $35,260
Total $35,260

Ownership

For profit - Limited Liability company Chain: MONARCH HEALTHCARE MANAGEMENT
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    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 01/01/2023

    100% Organization
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    5% OR GREATER INDIRECT OWNERSHIP INTEREST

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    NO PERCENTAGE PROVIDED Organization
  • HALPERT, MARC

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/01/2023

    NO PERCENTAGE PROVIDED Individual
  • JAFFA, NOAM

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/01/2023

    NO PERCENTAGE PROVIDED Individual
  • LEGUM, JOSHUA

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/01/2023

    NO PERCENTAGE PROVIDED Individual
  • STERN, WILLIAM

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/01/2023

    NO PERCENTAGE PROVIDED Individual
  • HALPERT, MARC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2023

    Individual
  • JAFFA, NOAM

    CORPORATE DIRECTOR

    Since since 01/01/2023

    Individual
  • HALPERT, MARC

    CORPORATE OFFICER

    Since since 01/01/2023

    Individual
  • STERN, WILLIAM

    CORPORATE OFFICER

    Since since 01/01/2023

    Individual
  • LEGUM, JOSHUA

    CONTRACTED MANAGING EMPLOYEE

    Since since 01/01/2023

    Individual

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