The Villa At Bryn Mawr

F-F638).

On 3/24/25 at 12:51 p.m., Resident R3 was observed in her room on the locked unit. Resident R3 had on a pair of flip-flop shoes on with no socks, which exposed both of her feet and toes. Resident R3's toenails were all long with the nail plate being several millimeters (mm) in length, and Resident R3 having visible hallux valgus (inward bend of the big toe) present on both feet. Resident R3 was asked about her toenails and if they had been clipped or trimmed recently to which Resident R3 responded aloud, I'd like to see the foot doctor again. Resident R3 stated she was unsure when they were last clipped or she had been seen by the podiatrist adding, I'm just losing track of time. Resident R3 stated she couldn't clip them herself, either, as she had poor balance.

When interviewed on 3/25/25 at 8:46 a.m., Resident R3's guardian (G)-A verified they were Resident R3's current guardian. G-A stated they had noticed Resident R3 to have long, thick toenails during their visits and had asked the care center to get Resident R3 into the onsite podiatry clinics, however, nobody from the care center ever knew when they'd (Podiatry) be onsite saying aloud, We don't know, we don't know. G-A stated Resident R3 needed to be seen for her toenails but there just seemed to always be quite a delay in that. Further, G-A stated Resident R3 having long toenails was probably why she has the flip-flops on [versus covered shoes].

Resident R3's care plan, dated 7/2023, identified Resident R3 had potential for skin breakdown due to several medical conditions including hallux valgus. The care plan listed interventions which included, Resident seen by podiatry (Often refuses visits).

Resident R3's progress note, dated 11/11/24, identified Resident R3 was seen by podiatry. The corresponding Healthdrive Podiatry Group note, dated 11/11/24, identified Resident R3 as the patient and listed her as non-diabetic. The note recorded Resident R3 as having moderate bunion deformity along with elongated, dystrophic and discolored nails on both feet. A section was listed labeled, Progress Note, which included dictation, Advised more frequent podiatry visits to reduce accumulation or hyperkeratotic tissue . Patient tolerated procedure well . Non-professional treatment is hazardous to the patient. The note concluded with no new orders and a note which read, Recall: As medically necessary but no sooner than 60 days. This was the last time Resident R3 had been seen by the podiatry clinic as recorded within her medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0687 When interviewed on 3/25/25 at 12:17 p.m., nursing assistant (NA)-B stated they had worked with Resident R3 multiple times prior, and described her (Resident R3) as accepting of most cares. NA-B stated they believed Resident R3 had Level of Harm - Minimal harm or been, at one time, seen by podiatry but was unsure when this had been. NA-B stated the onsite podiatry potential for actual harm group had just been there at the care center like three weeks ago but, again, was unsure if Resident R3 had been seen or not. NA-B stated Resident R3 needed her toenails clipped though still adding they looked kind of scary being Residents Affected - Few so long. NA-B stated Resident R3 had just told them earlier that day (3/25) podiatry was going to do adding some guy [surveyor] was helping her arrange it. NA-B stated the health information manager (HIM)-A helped arrange appointments and would be the person to talk with about podiatry visits.

On 3/25/25 at 12:31 p.m., HIM-A was interviewed, and verified they helped arrange the podiatry visits to the care center. HIM-A explained the podiatry services were done by an outside group who came to the care center. They would provide a list of patients to be seen to HIM-A who then also sent it to the nursing department. HIM-A stated they were aware Resident R3 needed to be seen by the podiatry group and expressed the group was last onsite on 2/13/25. However, at that time, Resident R3 was off the list and they were not sure if Resident R3 had been seen or not. HIM-A provided the contact person for the group' information and verified there was no record, at least which they could find, to show Resident R3 had been seen, offered or refused podiatry services on 2/13/25. HIM-A verified Resident R3 had signed consents for the service and, again, expressed they were not sure why Resident R3 had been removed from the list to be seen. HIM-A verified if the service had been offered and refused, then an entry into the medical record should have been done.

The provided Healthdrive Facsimile Cover Page, dated 1/24/25, identified the listing of patients to be seen via podiatry on 2/13/25. The page directed to inform the group if any add-on requests or priority patients were identified, and 20 patient names were listed. However, Resident R3's name was not included. On 3/25/25, an email was placed to the offsite podiatry group contact person, as provided by HIM-A, with a request to call. A response was received on 3/25/25, which outlined the email and request was forwarded to their supervisor adding, I am not sure when they will reach out to you. However, a return call was never received.

Resident R3's medical record was reviewed and lacked evidence Resident R3 had been offered or seen by podiatry on 2/13/25, despite the previous podiatry note calling for more visits and Resident R3 having long nails which needed to be addressed. Further, the record lacked evidence on what, if any, rationale or explanation for Resident R3 not being listed on the roster of patients to be treated.

When interviewed on 3/25/25 at 1:07 p.m., licensed practical nurse manager (LPN)-A stated HIM-A would be

the person who managed podiatry appointments for the care center. LPN-A stated floor staff should be reporting to HIM-A if anyone needed to be added to the list, and expressed nobody had told them (LPN-A) Resident R3 needed to be seen. LPN-A verified someone should have ensure Resident R3's nails were addressed adding having long, unkept nails could cause cuts in the skin or all kinds of issues.

On 3/25/25 at 2:49 p.m., the interim director of nursing (DON) was interviewed. DON stated they hadn't delved into the podiatry stuff since I've been here yet but acknowledged HIM-A helped managed it adding, Usually the HUC [HIM-A] is setting all that stuff up. DON stated nobody had reported, at least to her recall, Resident R3's long toenails to her.

A facility policy on podiatry appointments and services was requested, however, none was received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48299

Residents Affected - Few Based on observation, interview, and document review, the facility failed to provide routine range of motion (ROM) for 1 of 1 resident (Resident R63) reviewed for ROM who was dependent on staff for all activities of daily living (ADLs).

Findings include:

Resident R63's annual Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R63 had severe cognitive impairment and diagnoses of aphasia (brain disorder which affects how one speaks and understands language), stroke (occurs when blood vessel is blocked or bursts), and hemiplegia or hemiparesis (loss of muscle function on one side of body or partial weakness on one side of body). Resident R63 had impairment on one side of both upper and lower extremities and was dependent on staff for all activities of daily living, such as dressing, bed mobility, and transfers.

Resident R63's care plan intervention initiated 2/14/24, directed staff to provide gentle range of motion as tolerated with daily care.

Resident R63's Occupational Therapy Evaluation and Plan of Treatment dated 2/20/24, indicated Resident R63 had impaired ROM to right upper extremity and a goal to improve standing tolerance and transfer status.

Resident R63's Physical Therapy Evaluation and Plan of Treatment document dated 2/21/24, indicated Resident R63 had no movement in right lower extremity and a goal to improve transfer status. The document indicated nursing managed Resident R63's contracture impairment.

Resident R63's Physical Therapy Discharge Summary dated 3/25/24, indicated therapy discussed stretching to decrease contractures, and Resident R63's daughter demonstrated understanding. The document indicated Resident R63's prognosis to maintain current level of function was good with consistent staff follow-through.

Resident R63's Summary of Daily Skilled Services dated 8/28/24, indicated Resident R63's family member was aware of discharge from skilled therapy and plan to have Resident R63 on functional maintenance program with skilled therapy to maintain and not worsen Resident R63's contractures.

Resident R63's Physical Therapy Discharge Summary dated 8/28/24, indicated Resident R63 would be picked back up on functional maintenance program to maintain contractures and recommended a hoyer lift for transfers. The document stated the prognosis to maintain current level of function was good with consistent staff follow-through.

Resident R63's Summary of Daily Skilled Services dated 10/11/24, indicated Resident R63's family member was educated to complete functional maintenance program.

Resident R63's Summary of Daily Skilled Services dated 11/14/24, indicated Resident R63's family member was not comfortable stretching Resident R63 at that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Resident R63's Physical Therapy Discharge Summary dated 11/21/24, indicated discharge recommendations to use a hoyer lift for transfers and maximum assistance to propel wheelchair. The document stated the prognosis to Level of Harm - Minimal harm or maintain current level of function was good with consistent staff follow-through. potential for actual harm Resident R63's Therapy Screen document dated 11/27/24, indicated Resident R63 was recently discharged from therapy, and Residents Affected - Few Resident R63's family member was educated on how to stretch patient.

Resident R63's medication and treatment administration record printed 3/26/25, lacked documentation of nursing staff providing ROM to Resident R63.

Resident R63's Follow Up Question Report, dated 3/1/25 to 3/26/25, lacked documentation of the nursing assistants providing ROM to Resident R63.

During interview on 3/24/25 at 5:42 p.m., Resident R63's family member (FM)-K stated the facility did not provide Resident R63 with continuous range of motion or exercises, so FM-K stretched Resident R63 when they visited.

During observation on 3/26/25 at 7:47 a.m., nursing assistant (NA)-C and NA-G assisted Resident R63 to put on a sweater over Resident R63's clothes. Resident R63 had a hoyer sling underneath them, and NA-C and NA-G transferred Resident R63 from bed to wheelchair. Resident R63's right hand was limp, and Resident R63 used their left hand to move their right hand.

During interview on 3/26/25 at 7:59 a.m., NA-G stated Resident R63 was dependent on staff for all ADLs. NA-G stated Resident R63's morning cares included dressing, peri-cares, personal hygiene, and transferring into wheelchair. NA-G stated nursing and therapy notified nursing assistants about which residents required ROM and other exercises and charted exercises performed in point-of-care (program used to record and document resident information). NA-G stated they were not notified to complete exercises with Resident R63.

During interview on 3/26/25 at 8:21 a.m., NA-C stated Resident R63's morning routine included dressing, peri-cares, personal hygiene, and transferring into wheelchair for breakfast. NA-C stated they looked at resident care plan to know who needed assistance with exercises, and Resident R63 did not require assistance with exercises.

During interview on 3/26/25 at 11:01 a.m., licensed practical nurse (LPN)-D stated therapy knew who needed exercises and had their own program and charting. LPN-D stated therapy worked with Resident R63 previously and did not know of any ROM nursing staff were to provide for Resident R63.

During interview on 3/27/25 at 10:54 a.m., registered nurse (RN)-B stated therapy gave nursing communication forms for exercises staff should complete with residents. RN-B placed orders for the exercises communicated to them and updated nursing staff. RN-B reviewed Resident R63's care plan and stated they would need to discuss with therapy. RN-B stated range of motion helped residents maintain strength and movement and prevented stiffness.

During interview on 3/27/25 at 12:11 p.m., the director of nursing (DON) expected staff to follow resident care plan and kardex (document to reference resident information from the care plan). DON verified Resident R63's care plan and kardex directed Resident R63 to receive daily range of motion, and Resident R63's medical record lacked documentation of ROM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During interview on 3/27/25 at 12:27 p.m., the therapy program manager (TPM) stated therapy worked with Resident R63 in October to mid-November 2024 for range of motion and stretching. Therapy educated FM-K to Level of Harm - Minimal harm or provide range of motion for Resident R63. TPM stated FM-K was frequently with Resident R63 and thought FM-K's schedule potential for actual harm may have changed since then. TPM stated Resident R63's care plan for range of motion was in place before they were in their current role. Residents Affected - Few

The facility did not have a range of motion policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48299

Residents Affected - Few Based on observation, interview, and document review, the facility failed to comprehensively assess and implement behavioral interventions for 1 of 1 resident (Resident R46) reviewed for behavior of throwing dining ware.

Findings include:

Resident R46's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R46 had severe cognitive impairment, hallucinations, delusions, and no other behavioral symptoms or rejection of care. Resident R46 was independent with activities of daily living.

Resident R46's Medical Diagnosis list printed 3/27/25, included mild cognitive impairment of uncertain or unknown etiology, hypertension (high blood pressure), and schizophrenia (chronic mental illness characterized by a combination of symptoms which significantly impair a person's thinking, feeling, and behavior).

Resident R46's care plan printed 3/27/25, indicated a focus area of potential nutritional problem and identified Resident R46 had

a history of throwing plates and breaking china dishes. The care plan indicated an intervention to offer plastic plates prn (as needed) to prevent injury to self or others. The care plan indicated a focus area of mood/behavior, which specified resident has a history of behaviors in the dining room, such as throwing food from tray and sliding tray across the floor. Interventions directed staff to monitor and document on mood state/behaviors upon occurrence.

Resident R46's Behavior/Mood Record printed 3/27/25, did not have target behavior monitoring prior to 3/27/25.

Resident R46's Follow Up Question Report dated 3/1/25 to 3/27/25, indicated Resident R46's behavior, number of times behavior occurred during the shift, behavioral approaches, and trend as Not Applicable besides one entry on 3/24/25. The entry dated 3/24/25 indicated Resident R46's behavior as None noted, number of times behavior occurred during the shift as 0, behavior approaches as Offer food/snack, and trend as Stayed the same.

Resident R46's progress notes were reviewed dated 8/1/24 to 3/27/25. A note on 9/4/24 at 9:51 a.m., indicated Resident R46 picked up breakfast tray from dining room and threw their cereal over their head behind them on the way back to their room. Resident returned to room and slammed the door. ACP and social services to follow up as needed.

No other progress notes were noted related to Resident R46 throwing food or dining ware.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 During observation and interview on 3/24/25 at 7:06 p.m., a plate rolled from down the hallway, which aligned with the dining room where residents were seated and eating their meal. Staff and visitor moved to Level of Harm - Minimal harm or avoid contact with the rolling plate. Resident R46 wheeled self down the hallway, and staff directed for Resident R46 to place potential for actual harm their room tray and dishes in the designated dirty dish area. Resident R46 forcefully dumped the dishes and tray into

the dirty dish container. Multiple staff and culinary director in the dining area confirmed the observed Residents Affected - Few behavior happened often. The culinary director shrugged and stated mental health as the reason why Resident R46 threw dining ware, and the other staff did not reply.

During interview on 3/25/25 at 1:17 p.m., dietary aide (DA)-D stated Resident R46 threw dining ware all the time and was not sure why. DA-D stated staff tried to have Resident R46 use paper plates and were told the use of paper plates was a dignity issue.

On 3/26/25 at 9:00 a.m., Resident R46 opened their door, declined interview, and shut their door.

Resident R46's progress notes lacked documentation of Resident R46 throwing dining ware on 3/24/25.

During interview on 3/27/25 at 10:46 a.m., licensed practical nurse (LPN)-D stated Resident R46 received food in the dining area but ate in their room. Resident R46 was provided regular dining ware, was known to randomly throw dining ware, and could go weeks without throwing dining ware.

During interview on 3/27/25 at 11:04 a.m., registered nurse (RN)-B stated Resident R46 ate in their room and in the dining area. RN-B was aware of Resident R46 throwing dining ware a couple days ago and was not aware before then. RN-B reviewed Resident R46's care plan and stated staff could look at Resident R46's triggers and monitor Resident R46's mood to know when to give Resident R46 a plastic plate.

During interview on 3/27/25 at 11:12 a.m., nursing assistant (NA)-H stated Resident R46 broke plates all the time and threw food. NA-H stated nobody knew why Resident R46 threw dining ware and usually provided Resident R46 with regular plates besides today, in which Resident R46 received a gray colored type of plate.

During interview on 3/27/25 at 12:19 p.m., the director of nursing (DON) stated they had not heard of Resident R46 throwing dining ware until recently and questioned if staff were documenting on Resident R46. DON reviewed Resident R46's care plan intervention and stated there were no clear parameters and would rely on nursing judgement for when to give Resident R46 a plastic plate. DON stated there were safety concerns of others getting hit by Resident R46 throwing dining ware.

Via email correspondence on 3/28/25, the administrator indicated they did not have a policy specific to behavioral management and tracking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48299

Residents Affected - Many Based on observation, interview, and documentation, the facility failed to ensure opened food items were wrapped, labeled, dated, and disposed of by use by dates. The facility failed to ensure personal staff items were not stored next to resident food items. Further, the facility failed to ensure facial hair restraints were worn during meal service and hair nets were worn in the kitchen. In addition, the facility failed to ensure the kitchen's dish machine reached adequate temperature and pans and utensils were completely dry before storage to prevent bacterial growth. This had potential to affect all 98 residents who resided in the facility, staff, and visitors who consumed food from the main production kitchen, and specifically residents on station two who consumed food from the steam table.

Findings include:

During the initial kitchen tour on [DATE REDACTED] at 12:26 p.m., a few culinary staff were in the kitchen area without hair nets or facial hair covers. The dry storage area had two jackets which hung on racks with food items. One shelf had an opened container of Hormel nectar consistency thickened cranberry juice cocktail. The container was approximately three fourths full and was labeled ,d+[DATE REDACTED]. The container label indicated to refrigerate unused portion and discard if not used within ten days after opening. The freezer near the dry food storage had multiple items in plastic bags with the opening knotted closed without a label or date. Meat patties in their original container with a bratwurst label was opened and not wrapped or secured shut and did not have a date label. The walk-in cooler in the kitchen labeled B had two fans. One fan had thin grayish colored, fuzzy matter throughout approximately half of the fan blades. The other fan had four areas of brownish grayish colored fuzzy matter which were sticking out of the fan. The area above the fans had brownish grayish colored fuzzy matter to the area above the fans approximately a foot and a half by a quarter to half an inch. Two large containers were labeled marinara sauce with a written label to use by [DATE REDACTED]. One sandwich with cheese was wrapped in plastic without a label and not dated. The bread felt hard. One opened container of sour cream had a printed best by date of [DATE REDACTED] and no opened date, and an opened container of cottage cheese had a printed best by date of [DATE REDACTED] and dated ,d+[DATE REDACTED]. All staff then had hair nets on in the kitchen, however two staff with facial hair were not wearing beard nets. A refrigerator labeled C had a plastic water bottle with a name written on it and more than twelve pitchers of orange and other juice without a label and date. In the freezer across from refrigerator C, there was a plastic water bottle, two opened containers of carrot rolls without a date, and pastries in a plastic bag which were unlabeled and undated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an observation and interview on [DATE REDACTED] at 1:03 p.m., the culinary director (CD) stated food and drink items should have a label and date and they generally kept opened refrigerated products for three to five Level of Harm - Minimal harm or days. CD stated the cooks usually rotated food supplies, and CD also reviewed supplies on Mondays. CD potential for actual harm confirmed the jackets hanging on the dry storage racks and expected staff to hang their jackets in the kitchen closet. CD confirmed observation of the opened thickened liquid and stated they would toss the container. Residents Affected - Many CD confirmed the observations on unlabeled and unwrapped and/or opened items in the freezer by the dry storage. CD identified the products as brats, pork, chicken, cheese ravioli, and egg rolls. In the walk-in cooler labeled B, CD stated the marinara sauces and other items which were unlabeled or past their use by dates should not be used. CD stated opened dairy products were kept for five to seven days. CD confirmed

observations in refrigerator C and stated staff made juice from concentrate and stated there was usually a label with the date the juices were prepared on the shelf. CD confirmed observations in the freezer across from refrigerator C.

During continued interview, CD stated they had issues with staff not wearing hair nets and facial hair nets and confirmed the previous observations of staff not wearing hair nets or facial hair nets when in the kitchen area where food was prepared.

During continued observation and interview of the kitchen, dietary aide (DA)-A and DA-B washed dishes through the dish machine. The DAs stated they tested the temperature and sanitizer level of the dish machine to ensure the dish machine worked appropriately. DA-B stated they checked the temperature and sanitizer level earlier in the shift and believed the machine was a low temperature dish machine. DA-A ran

the dish machine to wash plastic pitchers, and the temperature gauge read 102 degrees Fahrenheit (F). DA-A tested the sanitizer level with the test strip a few times after restarting the dish machine, and the strip did not change color. The sanitizer container was empty, and DA-A stated they needed to change the bucket. The [DATE REDACTED] temperature and sanitizer level record was reviewed. The form had a blank area for when to report temperature and sanitizer levels. DA-B stated the sanitizer level was adequate this morning

during breakfast, and the dish machine temperature dropped at times and had to have maintenance check. DA-B stated a dish machine temperature of 115 degrees F or below was not safe.

During interview on [DATE REDACTED] at 1:42 p.m., the corporate culinary director (CCD) confirmed the observation of

the fans and above the fans in the walk-in refrigerator and stated the fans and area above needed to be cleaned.

During observation and interview on [DATE REDACTED] at 1:51 p.m., DA-A stated the sanitizer level was 100 ppm (parts per million) this morning and was not sure when the sanitizer solution ran out. The plastic pitchers were not rewashed as DA-A tested the sanitizer level after more sanitizing solution was placed. The test strip turned purple, and DA-A confirmed was an adequate level per the products' instructions and the dish machine temperature was 120 to 125 degrees F. Observation of further cycles, identified a temperature level of 110 degrees F.

During observation and interview on [DATE REDACTED] at 1:57 p.m., DA-A placed clean utensils in drawers which had visible condensation. DA-A stacked clean pans with condensation. DA-A observed a couple pans stacked and stated the dish machine should dry them and returned to the dish machine room. DA-A stated the temperature of the dish machine, which continued to be used, was 110 degrees F. The temperature gauge read 102 degrees F. DA-A placed a square yellow thermometer into the dish machine, which identified a temperature of 101 degrees F. The dish machine continued to be used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The American Dish Service dish machine with model number AFC3DS had a label, which indicated a minimum temperature of 120 degrees F and 50 ppm. Level of Harm - Minimal harm or potential for actual harm During observation of meal service on [DATE REDACTED] at 12:15 p.m., DA-A was behind the steam table and took the foods' temperature and dished up multiple plates for residents. DA-A had a facial hair on their chin Residents Affected - Many approximately a quarter inch to half an inch long and did not wear a facial hair restraint.

During observation and interview on [DATE REDACTED] at 1:38 p.m., DA-A and DA-C washed dishes through the dish machine. They stated the temperature earlier was 105 degrees F.

During subsequent interview, DA-C stated the dish machine temperature was supposed to get to 120 to 130 degrees F, and the dish machine temperature fluctuated. DA-C stated left over food was dated and labeled and kept for five days to a week. DA-C stated food out of original packaging should be labeled and dated. DA-C stated it was important to label and date food so other shifts knew when items needed to be used by. DA-C stated their jackets were stored in the closet and stored food brought from home in a refrigerator on station four. DA-C stated they were supposed to wear hair and facial hair restraints during meal service. DA-C stated they let dishes dry before stacking or dried with a towel if needed to dry faster.

During interview on [DATE REDACTED] at 1:56 p.m., DA-A confirmed they did not have a facial hair restraint on and stated they forgot.

During joint interview on [DATE REDACTED] at 11:21 a.m., the floating maintenance director (MD) and the regional maintenance director (RDOM) stated they were notified the dish machine temperature was not adequate.

They stated the temperature of the dish machine should be 140 to 160 degrees F and was 86 degrees F.

The dish machine needed to reach appropriate temperature to sanitize the dishes. There was a monthly cleaning schedule for the fans in the walk-in refrigerator. The fans had been cleaned in the past month and was cleaned again this week. The fans would have been cleaned the first week of April per their cleaning schedule. They expected staff to notify them if fans needed to be cleaned sooner than their monthly schedule. Fans were important to keep clean for sanitary reasons and longevity of the machine.

During interview on [DATE REDACTED] at 11:32 a.m., CD stated they did not know the fans in the walk-in refrigerator needed to be cleaned and maintenance knew more. CD expected dishes to dry on the rack before stacking. CD stated they had a low temperature dish machine, and the minimum temperature was 120 degrees F. CD stated they had maintenance looking at the dish machine and adequate function of the dish machine was important to make sure dishes were sanitized and germs killed.

During interview on [DATE REDACTED], the administrator expected food items to be labeled and dated to avoid serving residents expired food. The administrator stated jackets and personal plastic water bottles needed to be stored away from resident food items for sanitary purposes. The administrator expected dishes to dry before stacking for sanitary reasons.

The facility policy Dishwashing Machine Use dated [DATE REDACTED], directed dishes to air-dry. The policy directed the operator to check temperatures with each dishwashing machine cycle and frequently during dishwashing machine cycle and to report inadequate temperatures immediately to the supervisor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The facility policy Food Storage - Non Perishable dated ,d+[DATE REDACTED], indicated personal belongings or other non-food items would not be stored with food. Level of Harm - Minimal harm or potential for actual harm The facility policy Food Receiving and Storage dated [DATE REDACTED], indicated all foods stored in the refrigerator or freezer will be covered, labeled, and dated with use by date. Residents Affected - Many

The facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated [DATE REDACTED], directed staff to wear hair nets or caps and/or beard restraints to keep hair from contacting exposed food, clean equipment, utensils, and linens.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48299 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure appropriate personal Residents Affected - Few protective equipment (PPE) was used for 1 of 1 resident (Resident R63) who received cares and was on enhanced barrier precautions.

Findings include:

Resident R63's annual Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R63 had severe cognitive impairment and diagnoses of aphasia (brain disorder which affects how one speaks and understands language), stroke (occurs when blood vessel is blocked or bursts), and hemiplegia or hemiparesis (loss of muscle function on one side of body or partial weakness on one side of body). Resident R63 had impairment on one side of both upper and lower extremities and was dependent on staff for all activities of daily living, such as dressing, bed mobility, and transfers.

Resident R63's care plan printed 3/25/25, indicated Resident R63 was on enhanced barrier precautions (EBP) related to presence of tube feeding.

During observation on 3/26/25 at 7:47 a.m., nursing assistant (NA)-C and -G assisted Resident R63 to put on a sweater. One NA wore gloves and no gown, and the other NA did not wear gloves or gown. The scrubs of both NAs touched Resident R63's bed. Both NAs had gloves on and no gowns to transfer Resident R63 from the bed to wheelchair using a hoyer lift. NA-C and -G boosted Resident R63 up in the wheelchair.

During interview on 3/26/25 at 7:59 a.m., NA-G stated Resident R63 required total assistance and wore gloves to assist Resident R63. NA-G stated nurses wore gloves and gowns to assist Resident R63 with their feeding tube. NA-G verified Resident R63's door had a sign which indicated enhanced barrier precautions. The sign directed staff to wear gloves and gowns for high-contact resident care activities, which included dressing and transfers.

During interview on 3/26/25 at 8:21 a.m., NA-C stated they were supposed to wear gloves and a gown whenever they worked with Resident R63 and verified they did not wear a gown when Resident R63 was assisted.

During interview on 3/26/25 at 11:01 a.m., licensed practical nurse (LPN)-D stated residents who required enhanced barrier precautions had a sign on their room. LPN-D stated staff needed to wear a gown when

they worked with Resident R63's feeding tube but not with transfers or personal cares.

During interview on 3/27/25 at 10:54 a.m., registered nurse (RN)-B stated nurses were trained on enhanced barrier precautions and expected staff to follow the enhanced barrier precautions sign on Resident R63's door. RN-B stated staff followed enhanced barrier precautions to prevent infections and for the protection of residents and staff.

During interview on 3/27/25 at 12:11 p.m., the director of nursing (DON) expected staff to wear a gown and gloves during transfers and close cares for residents with enhanced barrier precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A facility policy Enhanced Barrier Precautions dated 4/1/24, directed staff to follow enhanced barrier precautions for residents with indwelling medical devices, which included feeding tubes. The policy identified Level of Harm - Minimal harm or enhanced barrier precautions referred to the use of gown and gloves during high-contact resident care potential for actual harm activities, and high-contact resident care activities, which included transferring, dressing, and device care.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49034

Residents Affected - Some Based on observation, interview, and document review, the facility failed to ensure the first-floor shower room was maintained in a clean, sanitary manner when the shower ceiling was observed with brown staining. This had the potential to affect 26 residents (including Resident R28, Resident R73, and Resident R304) who resided on the first floor and utilized the shower room on a routine basis.

Findings include:

Resident R28's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R28 had moderate cognitive impairment and resided on the first floor.

Resident R73's annual MDS dated [DATE REDACTED], indicated Resident R73 had intact cognition.

Resident R73's banner printed on 3/24/25, indicated Resident R73 resided on the first floor.

Resident R304's admission MDS dated [DATE REDACTED], indicated Resident R304 had intact cognition, was admitted to the facility on [DATE REDACTED], and resided on the first floor.

During an interview on 3/24/25 at 12:48 p.m., Resident R73 stated she believed the facility had black mold growing in

the shower room and felt unsafe using the shower related to this and felt it was a serious issue. Resident R73 stated

she was unsure when she had told staff but thought they were aware of the black mold.

During an observation and interview on 3/24/25 at 1:33 p.m., the ceiling above and to the right of the shower head when facing it, had an approximately one-foot by one-and-a-half-foot area of small, various spaced and sized, black/brown stains. Licensed practical nurse (LPN)-B stated he had not seen the stain before but thought it looked like mold and he would need to have maintenance look at it.

During an interview on 3/24/25 at 1:58 p.m., Resident R28 stated he had noticed the black stuff on the ceiling of the shower room for months. Resident R28 stated he had notified staff of the black stuff when he had first noticed it, but was told it was fine and did not receive any follow-up on if it was going to be fixed.

During an interview on 3/24/25 at 5:56 p.m., Resident R73 stated the ceiling in the shower room was gross. Resident R304 stated he had first noticed the black spots on the ceiling about two days after he was admitted and had used

the shower for the first time.

During an interview on 3/26/25 at 9:30 a.m., nursing assistant (NA)-A stated she would clean the shower room after each resident use, but housekeeping would be in charge of cleaning the black stain on the ceiling as it required a deeper cleaning. NA-A stated she had seen the stain before but was unsure how long it had been there. At 11:27 a.m., NA-A confirmed that they only had one shower for the floor and all 26 residents on

the unit used it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 245203 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245203 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at Bryn Mawr LLC 275 Penn Avenue North Minneapolis, MN 55405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 During an interview with housekeeping aide (HA)-A and the director of housekeeping (DOH) on 3/26/25 at 10:36 a.m., HA-A stated he had worked at the facility for about a year and the stain on the ceiling had been Level of Harm - Minimal harm or there since he started. HA-A stated he had attempted to clean the stain previously but was unable to remove potential for actual harm it so he had notified maintenance prior to the director of maintenance leaving in February, but it had never been fixed. The DOH stated he did not believe that the stain was mold but given its appearance could Residents Affected - Some understand why residents would think that. HA-A followed up by stating, he wouldn't like that in my shower either.

During an interview on 3/26/25 at 11:11 a.m., the regional director of maintenance (RDOM) stated he was filling in as the last maintenance director had left in February of this year. The RDOM stated he had not been made aware of the first-floor shower room ceiling staining until the being of this week. The RDOM acknowledged that he thought communication may have been an issue with the last maintenance director and may have led to the ceiling stain in the shower room not being addressed. The RDOM stated they would have to tear down that part of the wall/ceiling to address the issue and redo it in case this issue was related to moisture, although he did not think the staining was mold.

A policy regarding maintenance requests was made and a TELS Masters procedure dated 2019 was received. The procedure did not address an expected timeline for completing maintenance requests.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 245203