The Villas At Bryn Mawr LLC
Open-data reference.
The Villas At Bryn Mawr LLC is a for profit - limited liability company facility in MINNEAPOLIS, MN with 105 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $35K.
275 PENN AVENUE NORTH, MINNEAPOLIS, MN 55405
Phone: 6123774723
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 245203
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 105
- Residents
- 103
- In Hospital
- No
- County
- Hennepin
- Last Inspection
- Mar 27, 2025
- Special Focus
- SFF Candidate
Staffing Data
- RN Hours
- 0.66 (nat'l avg: 0.68)
- LPN Hours
- 0.58
- CNA Hours
- 1.45
- Total Nursing Hours
- 2.69 (nat'l avg: 3.89)
- PT Hours
- 0.02
- Nursing Turnover
- 29.5%
- RN Turnover
- 40.0%
What the CMS Record Reveals About The Villas At Bryn Mawr LLC
The Villas At Bryn Mawr LLC operates 105 certified beds in MINNEAPOLIS, MN with approximately 103 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (4★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $35K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 2.69 total nursing hours per resident day (national average 3.89), with RN coverage at 0.66 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, The Villas At Bryn Mawr LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 29.5%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 15, 2025
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.
Category: Resident Rights Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jul 18, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 18, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 10, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 18, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 18, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Apr 29, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 29, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 29, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 29, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 29, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 29, 2025
Assure that each resident’s assessment is updated at least once every 3 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 29, 2025
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Apr 29, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category: Resident Rights Deficiencies
Corrected: Apr 29, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Feb 14, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 3, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Sep 4, 2024
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Sep 4, 2024
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Category: Administration Deficiencies
Corrected: Sep 4, 2024
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Category: Environmental Deficiencies
Corrected: Sep 4, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 4, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Jun 14, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 14, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 14, 2024
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 14, 2024
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 14, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 14, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 14, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jun 14, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jun 14, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 8, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: May 3, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: May 3, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: May 3, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: May 3, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: May 3, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2023
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: May 3, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.3% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 14.1% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.7% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 94.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 70.9% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 4.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 6.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 10.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 95.4% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 57.1% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 8.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 24.4% | Yes |
Penalty History 1 penalties totaling $35K
| Date | Type | Amount |
|---|---|---|
| Aug 12, 2024 | Fine | $35K |
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Frequently Asked Questions
What is the overall CMS rating for The Villas At Bryn Mawr LLC?
What are the staffing levels at The Villas At Bryn Mawr LLC?
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Does The Villas At Bryn Mawr LLC have any deficiencies on record?
Has The Villas At Bryn Mawr LLC received any fines or penalties?
Who owns The Villas At Bryn Mawr LLC?
When was The Villas At Bryn Mawr LLC last inspected?
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.