Villas At Bryn Mawr LLC
Minneapolis, Hennepin County, Minnesota · CCN 245203 · For-profit (Corporation) · part of Monarch Healthcare Management (45 facilities, chain average 2.2 stars)
CMS rates Villas At Bryn Mawr LLC 1 of 5 overall as of August 2026. 105 certified beds, 97 residents a day on average. 57 citations on record from the current inspection cycles, 5 at immediate jeopardy; 2 fines totalling $51,980.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
- Special Focus Facility candidate. On CMS’s list of facilities that qualify for the program but are not yet in it.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 5 / 3 of 5 |
Staffing
| Total nurse staffing | 2.73418 hours per resident per day |
|---|---|
| Registered nurses | 0.68185 hours per resident per day |
| Weekend total | 2.53765 hours per resident per day |
| Nursing staff turnover | 29.2% (registered nurses 46.2%) |
| Administrators who left | 2 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-17 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 complaint survey |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 complaint survey |
Put firmly secured handrails on each side of hallways. Environmental Deficiencies · tag F0924 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · tag F0582 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-06-17 complaint survey |
Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-29 |
| 2026-03-13 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2026-04-07 |
| 2026-03-13 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-07 |
| 2026-02-27 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Past Non-Compliance |
| 2025-09-29 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-10-15 |
| 2025-09-11 complaint survey |
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. Resident Rights Deficiencies · tag F0578 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance |
| 2025-06-24 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance 2025-06-10 |
| 2025-06-24 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-18 |
| 2025-06-24 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-18 |
| 2025-06-24 complaint survey |
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. Quality of Life and Care Deficiencies · tag F0742 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-18 |
| 2025-06-24 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-18 |
| 2025-04-15 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · tag F0576 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · tag F0638 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Provide appropriate foot care. Quality of Life and Care Deficiencies · tag F0687 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 complaint survey |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · tag F0740 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-29 |
| 2025-03-27 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2025-04-29 |
| 2025-01-23 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-14 |
| 2025-01-14 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-03 |
| 2024-08-12 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
L Immediate jeopardy to resident health or safety; widespread | Deficient, Provider has date of correction 2024-09-04 |
| 2024-08-12 complaint survey |
Provide bedrooms that don't allow residents to see each other when privacy is needed. Environmental Deficiencies · tag F0914 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-04 |
| 2024-08-12 complaint survey |
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-04 |
| 2024-08-12 complaint survey |
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2024-09-04 |
| 2024-08-12 complaint survey |
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2024-09-04 |
| 2024-05-02 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | 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. Quality of Life and Care Deficiencies · tag F0693 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-02 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-06-14 |
| 2024-02-26 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-08 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-02-27 | Fine | $16,720 |
| 2024-08-12 | Fine | $35,260 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Monarch Healthcare Operating Xii LLC Organization | 5% or greater direct ownership interest | 100% | 2023-01-01 |
| Nij LLC Organization | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Spartan Healthcare LLC Organization | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Wbs Holdings LLC Organization | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Yazoma Holdings, LLC Organization | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Halpert, Marc Individual | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Jaffa, Noam Individual | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Legum, Joshua Individual | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Stern, William Individual | 5% or greater indirect ownership interest | — | 2023-01-01 |
| Legum, Joshua Individual | contracted managing employee | — | 2023-01-01 |
| Jaffa, Noam Individual | corporate director | — | 2023-01-01 |
| Halpert, Marc Individual | corporate officer | — | 2023-01-01 |
| Stern, William Individual | corporate officer | — | 2023-01-01 |
| Halpert, Marc Individual | operational/managerial control | — | 2023-01-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Villas At Bryn Mawr LLC.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Hennepin County.