01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-06-17 | 19 | 2026-06-17 | 13 |
| Cycle 2 | 2025-03-27 | 28 | 2025-03-27 | 8 |
| Cycle 3 | 2024-05-02 | 10 | 2024-05-02 | 8 |
CMS CCN 2452032026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Villas At Bryn Mawr Llc
275 Penn Avenue North · Minneapolis, MN 55405 · Hennepin County
Certified beds105CMS provider file
Recent citation rows86current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
86 rows in the current release
6 rows carry G–L scope/severity codes; 5 carry J–L. 20 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-17 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0605Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · HEALTHF0919Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has plan of correction · 2026-07-29 · complaint2026-06-17 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has plan of correction · 2026-07-29 · complaint2026-06-17 · HEALTHF0924Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
Correction field: Deficient, Provider has plan of correction · 2026-07-29 · complaint2026-06-17 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0353Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0541Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Correction field: Deficient, Provider has plan of correction · 2026-07-292026-06-17 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has plan of correction · 2026-07-2903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-02-27 | Fine | $16,720 | 0 |
| 2024-08-12 | Fine | $35,260 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MONARCH HEALTHCARE OPERATING XII LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/2023
- NIJ LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- SPARTAN HEALTHCARE LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- WBS HOLDINGS LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- YAZOMA HOLDINGS, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- HALPERT, MARCIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- JAFFA, NOAMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- LEGUM, JOSHUAIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- STERN, WILLIAMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2023
- LEGUM, JOSHUAIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2023
- JAFFA, NOAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- HALPERT, MARCIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2023
- STERN, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2023
- HALPERT, MARCIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.73per resident day
RN hours0.68per resident day
Weekend nurse hours2.54per resident day
Staff turnover29.2%CMS reported field
06 / LOCAL RECORDS
Open the Minneapolis ledger →Other published facilities nearby
Andrew Residence212 beds · CMS overall 2/540 citation rowsBenedictine Health Center Of Minneapolis90 beds · CMS overall 3/532 citation rowsBirchwood Care Home60 beds · CMS overall 5/568 citation rowsBywood East Health Care96 beds · CMS overall 2/5106 citation rowsCatholic Eldercare On Main164 beds · CMS overall 3/551 citation rowsEdenbrook Of Edina80 beds · CMS overall 3/556 citation rowsFairview University Trans Serv28 beds · CMS overall 5/50 citation rowsGrand Avenue Rest Home20 beds · CMS overall 3/556 citation rows