Federal inspection record · CMS data as of October 1, 2026
Villas At Bryn Mawr LLC
275 Penn Avenue North, Minneapolis, MN · (612) 377-4723
- Special Focus Facility
- Certified beds
- 105
- Residents per day
- 98
- Ownership
- For-Profit
- Chain
- Monarch Healthcare Management
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- October 1, 1978
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Minnesota.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Minnesota homes
Villas At Bryn Mawr LLC carries 226.75 inspection points. That is fewer than 1% of Minnesota's 335 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Minnesota: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9 pts
- 4★ 9–30 pts
- 3★ 30–54 pts
- 2★ 54–92 pts
- 1★ over 92 pts
Bars show every rated home in Minnesota by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
57 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (6)
-
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
J
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.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
L
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care16E
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide enough food/fluids to maintain a resident's health.
- D
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.
- D
Provide enough food/fluids to maintain a resident's health.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Assist a resident in gaining access to vision and hearing services.
- D
Provide appropriate foot care.
- D
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.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
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.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Resident Rights8D
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
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.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Ensure residents have reasonable access to and privacy in their use of communication methods.
- B
Keep residents' personal and medical records private and confidential.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
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.
Environmental5E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- E
Put firmly secured handrails on each side of hallways.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Resident Assessment and Care Planning5D
- D
Ensure each resident receives an accurate assessment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Pharmacy Service4D
- D
Ensure 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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Infection Control4E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Freedom from Abuse, Neglect, and Exploitation3E
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Administration3D
- D
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- B
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- B
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Nutrition and Dietary2F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Inspection history
2026-06-17
17 health deficiencies · 13 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2025-03-27
25 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
2024-05-02
15 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 46 min of nursing staff time a day, 39 min of it from a registered nurse.
This home
2 h 46 min
Minnesota average
4 h 16 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 29% of nursing staff and 47% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$105,505 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-03-13 | Fine | $53,525 |
| 2026-02-27 | Fine | $16,720 |
| 2024-08-12 | Fine | $35,260 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts better | 1.2 | 1.5 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.5 pts worse | 2.2 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.5 pts better | 97.8% | 97.3% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.7 pts better | 97.1% | 96.4% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.7 pts better | 3.4% | 4.1% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.3 pts worse | 6.4% | 4.1% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.8 pts better | 2.1% | 3.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.4 pts better | 12.3% | 12.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.5 pts worse | 22.7% | 17.2% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened14.5 pts better | 4.3% | 18.8% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased12.4 pts better | 5.8% | 18.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.5 pts better | 0.2% | 1.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.3 pts better | 0.3% | 2.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence14.4 pts better | 9.3% | 23.7% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.6 pts better | 2.5% | 5.1% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine12.2 pts worse | 75.9% | 88.1% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.9 pts worse | 22.5% | 14.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1 pts better | 0.9% | 1.9% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine7.6 pts worse | 75.7% | 83.3% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission13.3 pts better | 9.7% | 23.0% | 23.4% |
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Who owns and runs it
14 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Monarch Healthcare Operating Xii LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 11 facilities |
| Halpert, Marc | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 45 facilities |
| Halpert, Marc | Corporate Officer · Individual | 0% | 45 facilities |
| Halpert, Marc | Operational/Managerial Control · Individual | 0% | 45 facilities |
| Jaffa, Noam | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 45 facilities |
| Jaffa, Noam | Corporate Director · Individual | 0% | 45 facilities |
| Legum, Joshua | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 45 facilities |
| Legum, Joshua | Contracted Managing Employee · Individual | 0% | 45 facilities |
| Nij LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 44 facilities |
| Spartan Healthcare LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 45 facilities |
| Stern, William | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 45 facilities |
| Stern, William | Corporate Officer · Individual | 0% | 45 facilities |
| Wbs Holdings LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 26 facilities |
| Yazoma Holdings, LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 44 facilities |
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Fire safety
29 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke13F
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Install corridor and hallway doors that block smoke.
- C
Inspect, test, and maintain automatic sprinkler systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
Egress5E
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Gas, Vacuum, and Electrical Systems3F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Have power receptacles that are properly grounded.
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Services3E
- E
Install properly constructed and protected linen or trash chutes.
- D
Have properly installed electrical wiring and gas equipment.
- E
Have properly installed electrical wiring and gas equipment.
Miscellaneous3E
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- C
Have simulated fire drills held at unexpected times.
- C
Have simulated fire drills held at unexpected times.
Emergency Preparedness2C
- C
Create arrangements with other facilities to receive patients.
- C
Develop and maintain an Emergency Preparedness Program (EP).
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Other homes nearby
-
Courage Kenny Rehabilitation Institutes Trp
Golden Valley, MN
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 7 h 52 min
- Fines
- $16,355
-
Southside Care Center
Minneapolis, MN · Special Focus
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 2 h 4 min
- Fines
- $0
-
Jones Harrison Residence
Minneapolis, MN · Ebenezer Senior Living
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 58 min
- Fines
- $0