Villas at Bryn Mawr LLC
275 Penn Avenue North, Minneapolis, MN 55405
Villas at Bryn Mawr LLC is a nursing home in Minneapolis, Minnesota. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (612) 377-4723
- Last standard health inspection
- June 17, 2026 (4 months ago)
- Certified beds
- 105
- Residents per day, on average
- 97.8
- Ownership type
- For profit - Corporation
- Legal business name
- Villas at Bryn Mawr LLC
- Chain
- Monarch Healthcare Management
- Takes part in
- Medicare and Medicaid
More health citations than the Minnesota average (57 vs 23).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of October 8, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of July 29, 2026
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
14 citations
Health inspection on June 17, 2026
CMS lists this as a standard inspection and a complaint inspection.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for F0609 2 times since 2025.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for F0921 2 times since 2025.
Citation F0924. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Put firmly secured handrails on each side of hallways.
CMS lists it as corrected on July 29, 2026.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on July 29, 2026.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on July 29, 2026.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for F0584 2 times since 2024.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on July 29, 2026.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on July 29, 2026.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on July 29, 2026.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for F0657 2 times since 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for F0684 4 times since 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for F0880 3 times since 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on July 29, 2026.
13 citations
Fire safety inspection on June 17, 2026
CMS lists this as a standard inspection.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 29, 2026.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2026.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for K0321 2 times since 2024.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 29, 2026.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on July 29, 2026.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for K0372 2 times since 2025.
Citation K0541. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on July 29, 2026.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on July 29, 2026.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for K0211 2 times since 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for K0363 3 times since 2024.
Citation K0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on July 29, 2026.
Citation K0353. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for K0353 3 times since 2024.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 29, 2026.
CMS has cited this home for K0712 2 times since 2025.
CMS update of April 29, 2026
Name
CMS lists a new name for this home. It was The Villas At Bryn Mawr LLC.
2 citations
Health inspection on March 13, 2026
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
47 of 337 Minnesota homes (14%) got a citation at the immediate jeopardy level in 2026.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 7, 2026.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 7, 2026.
CMS has cited this home for F0692 2 times since 2025.
Fine
March 13, 2026 (7 months ago)
CMS fine of $53,525 on March 13, 2026.
1 citation
Health inspection on February 27, 2026
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
53 of 337 Minnesota homes (16%) got a citation at the actual harm level in 2026.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS has cited this home for F0686 2 times since 2024.
Fine
February 27, 2026 (8 months ago)
CMS fine of $16,720 on February 27, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of December 15, 2025
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
1 citation
Health inspection on September 29, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on October 15, 2025.
1 citation
Health inspection on September 11, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0578. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
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.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
5 citations
Health inspection on June 24, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 10, 2025.
CMS has cited this home for F0689 2 times since 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 18, 2025.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 18, 2025.
Citation F0742. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 18, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 18, 2025.
CMS has cited this home for F0755 2 times since 2025.
CMS update of May 28, 2025
Fine
CMS changed the fine from August 12, 2024 from $54,245 to $35,259.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 5 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.1 to 2.6 hours per resident per day.
1 citation
Health inspection on April 15, 2025
CMS lists this as a complaint inspection.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 29, 2025.
15 citations
Health inspection on March 27, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 29, 2025.
CMS has cited this home for F0812 2 times since 2024.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 29, 2025.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on April 29, 2025.
Citation F0576. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on April 29, 2025.
Citation F0638. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assure that each resident’s assessment is updated at least once every 3 months.
CMS lists it as corrected on April 29, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on April 29, 2025.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on April 29, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 29, 2025.
CMS has cited this home for F0677 2 times since 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on April 29, 2025.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on April 29, 2025.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 29, 2025.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on April 29, 2025.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 29, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 29, 2025.
Citation F0583. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on April 29, 2025.
8 citations
Fire safety inspection on March 27, 2025
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 29, 2025.
Citation K0225. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on April 29, 2025.
CMS has cited this home for K0225 2 times since 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 29, 2025.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on April 29, 2025.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on April 29, 2025.
Citation K0914. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on April 29, 2025.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 29, 2025.
CMS has cited this home for K0511 2 times since 2024.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 29, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on January 23, 2025
CMS lists this as a complaint inspection.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 14, 2025.
1 citation
Health inspection on January 14, 2025
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 3, 2025.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Staffing
Total nurse staffing reported to CMS went from 3.1 to 2.6 hours per resident per day.
CMS update of August 29, 2024
Fine
CMS changed the fine from September 17, 2021 from $22,504 to $23,048.
5 citations
Health inspection on August 12, 2024
CMS lists this as a complaint inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
54 of 337 Minnesota homes (16%) got a citation at the immediate jeopardy level in 2024.
Citation F0689. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 4, 2024.
Citation F0914. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide bedrooms that don't allow residents to see each other when privacy is needed.
CMS lists it as corrected on September 4, 2024.
Citation F0949. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on September 4, 2024.
Citation F0941. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on September 4, 2024.
Citation F0944. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on September 4, 2024.
Fine
August 12, 2024 (2 years ago)
CMS fine of $35,260 on August 12, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of May 29, 2024
Fine
CMS changed the fine from September 17, 2021 from $20,775 to $22,504.
9 citations
Health inspection on May 2, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 14, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 14, 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on June 14, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 14, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 14, 2024.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 14, 2024.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on June 14, 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on June 14, 2024.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on June 14, 2024.
8 citations
Fire safety inspection on May 2, 2024
CMS lists this as a standard inspection.
Citation K0225. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on June 14, 2024.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 14, 2024.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on June 14, 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 14, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 14, 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 14, 2024.
Citation E0004. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on June 14, 2024.
Citation E0025. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Create arrangements with other facilities to receive patients.
CMS lists it as corrected on June 14, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of March 28, 2024
Fine
CMS changed the fine from August 27, 2021 from $233,308 to $152,367.
CMS update of February 29, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Fine
CMS changed the fine from August 27, 2021 from $152,367 to $233,308.
1 citation
Health inspection on February 26, 2024
CMS lists this as a complaint inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 8, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Fine
CMS changed the fine from August 27, 2021 from $234,410 to $152,367.
Fine
CMS changed the fine from January 5, 2022 from $18,880 to $12,272.
CMS update of December 21, 2023
Health citation
CMS changed citation F0600 from severity J to D. It is from the health inspection on July 25, 2022. Severity D: potential for more than minimal harm, isolated.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- MONARCH HEALTHCARE OPERATING XII LLC5% or greater direct ownership interest · 100% · since 01/01/2023
- NIJ LLC5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- SPARTAN HEALTHCARE LLC5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- WBS HOLDINGS LLC5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- YAZOMA HOLDINGS, LLC5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- HALPERT, MARC5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- JAFFA, NOAM5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- LEGUM, JOSHUA5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- STERN, WILLIAM5% or greater indirect ownership interest · no percentage provided · since 01/01/2023
- HALPERT, MARCOperational/managerial control · not applicable · since 01/01/2023
Questions
When was Villas at Bryn Mawr LLC last inspected?
CMS lists June 17, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Villas at Bryn Mawr LLC have?
CMS lists 57 health citations since February 26, 2024. CMS also calls these deficiencies.
Has Villas at Bryn Mawr LLC been fined?
CMS lists 3 fines in the past three years, $105,505 in total.
What is the CMS star rating of Villas at Bryn Mawr LLC?
Its CMS overall star rating is 1 of 5.
Is Villas at Bryn Mawr LLC a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.