Map showing the location of The Villas At Bryn Mawr LLC in MINNEAPOLIS, Minnesota
275 PENN AVENUE NORTH, MINNEAPOLIS, MN, 55405

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • MinnesotaLowest tier among peers337 rated homes · average 3.2★
  • Hennepin CountyLowest tier among peers53 rated homes · average 3.1★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs MN avg
  • StaffingCan add or remove a star4★−0.1 vs MN avg
  • Quality measuresCan add or remove a star4★+0.8 vs MN avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMN avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 22% of peersMN avg4.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 61% of peersMN avg3.2★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff2.69hrsAbove only 2% of peersMN avg4.23Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.66hrsAbove only 14% of peersMN avg1.06Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better30%Above 81% of peersMN avg42%RN turnover40%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$35,260Above only 15% of peersMN avg$19,953Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
58citations
11inspection dates
0actual harm (G–I)
4immediate jeopardy (J–L)
Sep 29, 2025most recent

Citations by monthMar 2023 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 29, 20251 citationCycle 1worst J · immediate jeopardy
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Oct 15, 2025
Sep 11, 20251 citationCycle 1worst J · immediate jeopardy
  1. F578Honor 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.Resident RightsJ · isolatedCorrection pending
Jun 24, 20255 citationsCycle 1worst J · immediate jeopardy
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Jun 10, 2025
  2. F742Provide 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.Quality of Life and CareD · isolatedCorrected Jul 18, 2025
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 18, 2025
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 18, 2025
  5. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jul 18, 2025
Apr 15, 20251 citationCycle 1worst D · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Apr 29, 2025
Mar 27, 202515 citationsCycle 1worst F · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 29, 2025
  2. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Apr 29, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Apr 29, 2025
  4. Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care PlanningD · isolatedCorrected Apr 29, 2025
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 29, 2025
  6. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Apr 29, 2025
  7. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Apr 29, 2025
  8. F583Keep residents' personal and medical records private and confidential.Resident RightsB · patternCorrected Apr 29, 2025
  9. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Apr 29, 2025
  10. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Apr 29, 2025
  11. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 29, 2025
  12. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Apr 29, 2025
  13. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Apr 29, 2025
  14. F688Provide 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.Quality of Life and CareD · isolatedCorrected Apr 29, 2025
  15. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 29, 2025
Jan 23, 20251 citationCycle 2worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 14, 2025
Jan 14, 20251 citationCycle 2worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 3, 2025
Aug 12, 20245 citationsCycle 2worst L · immediate jeopardy$35,260
  1. F914Provide bedrooms that don't allow residents to see each other when privacy is needed.EnvironmentalD · isolatedCorrected Sep 4, 2024
  2. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationB · patternCorrected Sep 4, 2024
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareL · widespreadCorrected Sep 4, 2024
  4. F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationB · patternCorrected Sep 4, 2024
  5. F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationD · isolatedCorrected Sep 4, 2024
May 2, 20249 citationsCycle 2worst F · no actual harm
  1. F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Jun 14, 2024
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jun 14, 2024
  3. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 14, 2024
  4. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Jun 14, 2024
  5. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Jun 14, 2024
  6. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Jun 14, 2024
  7. F584Honor 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.Resident RightsD · isolatedCorrected Jun 14, 2024
  8. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jun 14, 2024
  9. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Jun 14, 2024
Feb 26, 20241 citationCycle 2worst D · no actual harm
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 8, 2024
Mar 9, 202318 citationsCycle 3worst F · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 3, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 3, 2023
  3. F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 3, 2023
  4. F742Provide 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.Quality of Life and CareD · isolatedCorrected May 3, 2023
  5. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 3, 2023
  6. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected May 3, 2023
  7. F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 3, 2023
  8. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected May 3, 2023
  9. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 3, 2023
  10. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalF · widespreadCorrected May 3, 2023
  11. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected May 3, 2023
  12. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected May 3, 2023
  13. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 3, 2023
  14. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 3, 2023
  15. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected May 3, 2023
  16. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected May 3, 2023
  17. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 3, 2023
  18. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 3, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined2.69hrsAbove only 2% of peers−1.54 vs MN avg
  • Registered nursesRN hours only0.66hrsAbove only 14% of peers−0.40 vs MN avg
  • Licensed practical nursesLPN hours0.58hrs
  • Nurse aidesCNA hours1.45hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.42hrs
  • Minnesota average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better30%Above 81% of peersMN avg 42%
  • RN turnoverRegistered nurses only40%Not ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy105 certified beds · ~103 residents a day98%Top 1%MN avg 83%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $35,260In fines
  • 1Fine
  • 0Payment denials
  • $19,953MN avg in fines
Above only 15% of peersFewer fines than 15% of rated homes in Minnesota

Actions on record

  1. Aug 12, 2024Civil money penalty$35,260

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Monarch Healthcare Management45 facilities in the chain2.3★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Monarch Healthcare Operating Xii LLC
Indirect owners (5%+)
  • Nij LLC
  • Spartan Healthcare LLC
  • Wbs Holdings LLC
  • Yazoma Holdings, LLC
  • Marc Halpert
  • Noam Jaffa
  • Joshua Legum
  • William Stern
Operational or managerial control
  • Marc Halpert
Corporate directors
  • Noam Jaffa
Corporate officers
  • Marc Halpert
  • William Stern
Contracted managers
  • Joshua Legum

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 245203 · 275 PENN AVENUE NORTH, MINNEAPOLIS, MN, 55405.
  • Percentiles compare this facility with every rated nursing home in Minnesota and Hennepin County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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