Villas At Bryn Mawr Llc
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.
Inspection Findings
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
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.