The Villas At Bryn Mawr Llc
For profit - Individual · 275 Penn Avenue North, Minneapolis, MN 55405 · See home’s Medicare page
Affiliated With Monarch Healthcare Management
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
3.06
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 4.2
56.9%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 45.2%
105
Certified beds
Qualifying beds in the certified provider or supplier facility.
89
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Monarch Healthcare Operating Xii Llc (100%)
Indirect owners
Nij Llc
Spartan Healthcare Llc
Wbs Holdings Llc
Yazoma Holdings, Llc
Marc Halpert
Noam Jaffa
Joshua Legum
William Stern
Spartan Healthcare Llc
Wbs Holdings Llc
Yazoma Holdings, Llc
Marc Halpert
Noam Jaffa
Joshua Legum
William Stern
Managerial control
Marc Halpert since Jan, 2023
Managing employee(s)
Joshua Legum since Jan, 2023
Inspection Reports
57
total deficiencies
3
infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Many people affected
Seriousness
Environmental Deficiency — F0914
Failure to:
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0949
Failure to:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0941
Failure to:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity
No actual harm, with potential for minimal harm
Scope
Some people affected
Seriousness
Administration Deficiency — F0944
Failure to:
Conduct mandatory training, for all staff, on the facility's Quality Assurance and Performance Improvement Program.
Severity
No actual harm, with potential for minimal harm
Scope
Some people affected
Seriousness
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0554
Failure to:
Allow residents to self-administer drugs if determined clinically appropriate.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0584
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0693
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0699
Failure to:
Provide care or services that was trauma informed and/or culturally competent.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0883
Failure to:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nursing and Physician Services Deficiency — F0732
Failure to:
Post nurse staffing information every day.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
Quality of Life and Care Deficiency — F0686
Failure to:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Environmental Deficiency — F0921
Failure to:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0645
Failure to:
PASARR screening for Mental disorders or Intellectual Disabilities
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0553
Failure to:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0558
Failure to:
Reasonably accommodate the needs and preferences of each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0580
Failure to:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0655
Failure to:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0658
Failure to:
Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0691
Failure to:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0742
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0755
Failure to:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0757
Failure to:
Ensure each resident's drug regimen must be free from unnecessary drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0758
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0759
Failure to:
Ensure medication error rates are not 5 percent or greater.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0843
Failure to:
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to:
Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0755
Failure to:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0558
Failure to:
Reasonably accommodate the needs and preferences of each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0755
Failure to:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Nutrition and Dietary Deficiency — F0804
Failure to:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Nutrition and Dietary Deficiency — F0809
Failure to:
Ensure meals and snacks are served at times in accordance with resident's needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Quality of Life and Care Deficiency — F0686
Failure to:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0760
Failure to:
Ensure that residents are free from significant medication errors.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Resident Rights Deficiency — F0554
Failure to:
Allow residents to self-administer drugs if determined clinically appropriate.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0678
Failure to:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident's advance directives.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0803
Failure to:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0567
Failure to:
Honor the resident's right to manage his or her financial affairs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0580
Failure to:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0800
Failure to:
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0846
Failure to:
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
Penalties
$33.9K
total fines
2
payment suspensions
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.