Skip to main content
Health Inspection

Villas At Bryn Mawr Llc

March 27, 2025 · Minneapolis, MN · 275 Penn Avenue North
Citations 1
CMS Rating 1/5
Beds 105
Provider ID 245203
Healthcare Facility
Villas At Bryn Mawr Llc
Minneapolis, MN  ·  View full profile →
Inspection Summary

Villas At Bryn Mawr LLC in MINNEAPOLIS, MN — inspection on March 27, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF638
Minimal harm or cataract surgery consult at HCMC and believed R3's appointed guardian had been notified of it. However, A affected

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

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

During interview on 3/26/25 at 7:59 a.m., NA-G stated R63 was dependent on staff for all ADLs. NA-G stated 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 R63.

During interview on 3/26/25 at 8:21 a.m., NA-C stated 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 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 R63 previously and did not know of any ROM nursing staff were to provide for 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 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 R63's care plan and kardex directed R63 to receive daily range of motion, and R63's medical record lacked documentation of ROM.

245203

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MINNEAPOLIS, MN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Villas At Bryn Mawr LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement