Villas At Bryn Mawr Llc
VILLAS AT BRYN MAWR LLC in MINNEAPOLIS, MN — inspection on September 11, 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
jeopardy to resident health or safety
a code blue, how to check a resident's POLST in the computer system, who can provide CPR, communication during and after a code blue, the crash cart, and CPR certification.
The education was followed up by a quiz.
The facility also completed an audit to ensure all licensed nurses had current basic life support (BLS) certifications.
The facility completed a full audit to check resident's code statuses to ensure what they had in paper matched what was on the resident's care plan and the resident's profile in the computer system.
The facility reviewed their CPR policy.
The facility had completed CPR drills and code blue drills on all staff on all shifts. RN-A and LPN-B were provided a corrective action plan and further education about CPR and the process of a code blue.
Administration completed full mock codes with RN-A and LPN-B. RN-A and LPN-B were suspended during this investigation.
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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.