Deficiency timeline
Villas At Bryn Mawr LLC
Dated inspection findings, penalties, and correction notes for this nursing home in Minneapolis, MN. Newest events first.
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Apr 7, 2026
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0692: Quality of Life and Care
Quality of life & care
Provide enough food/fluids to maintain a resident's health.
Corrected Apr 7, 2026
- Class IIActual harm (G)Complaint-relatedcms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Fine $16,720cms
CMS fine
Civil money penalty recorded in CMS Nursing Home Compare.
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0600: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Oct 15, 2025
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0578: Resident Rights
Resident rights
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.
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Jun 10, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Jul 18, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0657: Resident Assessment and Care Planning
Assessment & care planning
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected Jul 18, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0742: Quality of Life and Care
Quality of life & care
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.
Corrected Jul 18, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0755: Pharmacy Service
Pharmacy services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Jul 18, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0692: Quality of Life and Care
Quality of life & care
Provide enough food/fluids to maintain a resident's health.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0685: Quality of Life and Care
Quality of life & care
Assist a resident in gaining access to vision and hearing services.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0687: Quality of Life and Care
Quality of life & care
Provide appropriate foot care.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0688: Quality of Life and Care
Quality of life & care
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.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0740: Quality of Life and Care
Quality of life & care
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0758: Pharmacy Service
Pharmacy services
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.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Apr 29, 2025
- Class IVMinimal harm / potential for minimal harm (B)cms
F0583: Resident Rights
Resident rights
Keep residents' personal and medical records private and confidential.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0812: Nutrition and Dietary
Nutrition & dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (E)cms
F0921: Environmental
Environment
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0576: Resident Rights
Resident rights
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0638: Resident Assessment and Care Planning
Assessment & care planning
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0645: Resident Assessment and Care Planning
Assessment & care planning
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0676: Quality of Life and Care
Quality of life & care
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (E)cms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Apr 29, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0755: Pharmacy Service
Pharmacy services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Feb 14, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Feb 3, 2025
- Class IVMinimal harm / potential for minimal harm (B)Complaint-relatedcms
F0941: Administration
Administration
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected Sep 4, 2024
- Class IImmediate jeopardy (L)Complaint-relatedcms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Sep 4, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0914: Environmental
Environment
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected Sep 4, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0949: Administration
Administration
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected Sep 4, 2024
- Class IVMinimal harm / potential for minimal harm (B)Complaint-relatedcms
F0944: Administration
Administration
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected Sep 4, 2024
- Fine $35,260cms
CMS fine
Civil money penalty recorded in CMS Nursing Home Compare.
- Class IIIPotential for more than minimal harm (D)cms
F0554: Resident Rights
Resident rights
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0584: Resident Rights
Resident rights
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.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0693: Quality of Life and Care
Quality of life & care
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.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0699: Quality of Life and Care
Quality of life & care
Provide care or services that was trauma informed and/or culturally competent.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0883: Infection Control
Infection control
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected Jun 14, 2024
- Class IVMinimal harm / potential for minimal harm (C)cms
F0732: Nursing and Physician Services
Nursing & physician services
Post nurse staffing information every day.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (F)cms
F0812: Nutrition and Dietary
Nutrition & dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (E)cms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Jun 14, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Mar 8, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0553: Resident Rights
Resident rights
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0558: Resident Rights
Resident rights
Reasonably accommodate the needs and preferences of each resident.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0580: Resident Rights
Resident rights
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0655: Resident Assessment and Care Planning
Assessment & care planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0656: Resident Assessment and Care Planning
Assessment & care planning
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0658: Resident Assessment and Care Planning
Assessment & care planning
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0691: Quality of Life and Care
Quality of life & care
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0742: Quality of Life and Care
Quality of life & care
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.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0755: Pharmacy Service
Pharmacy services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0757: Pharmacy Service
Pharmacy services
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0758: Pharmacy Service
Pharmacy services
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.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0759: Pharmacy Service
Pharmacy services
Ensure medication error rates are not 5 percent or greater.
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (E)cms
F0645: Resident Assessment and Care Planning
Assessment & care planning
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected May 3, 2023
- Class IIIPotential for more than minimal harm (F)cms
F0921: Environmental
Environment
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected May 3, 2023
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AHCA class rollups without individual citation dates appear as a single summary row. CMS nursing home deficiencies include survey date, tag, category, scope/severity, and fine amounts when published. Back to community profile