F
Southside Care Center
26/100 score
0.92 hrs RN staffing
27 deficiencies
Villas At Bryn Mawr LLC
275 PENN AVENUE NORTH, MINNEAPOLIS, MN 55405
Operator
MONARCH HEALTHCARE OPERATING XII · 11 facilities
- Provider number (CCN)
- 245203
- Certification
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified beds
- 105
- Phone
- (612) 377-4723
- CMS data as of
- July 1, 2026
F
What the records show
CMS rates Villas At Bryn Mawr LLC 1 out of 5 stars overall, with 1 of 5 for health inspections, 4 of 5 for staffing, 4 of 5 for quality measures. Federal inspectors cited 61 health deficiencies across the last three survey cycles, most recently surveyed in 2025, 6 at actual-harm level or higher. CMS enforcement records list 2 fines totalling $51,980.
Facility Assessment
Inspectors recorded 6 citations at the actual-harm level or worse in the last three survey cycles.
Reviews, Ratings and Official Records
This page reviews Villas At Bryn Mawr LLC using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.
At or above the 2024 benchmark — review inspection history before visiting.
Ratings and Grade Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.68 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
61
Outstanding
0
Actual harm or worse (G–L)
6
|
|
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
|
Overall: ★☆☆☆☆ (1/5)
Health inspection: ★☆☆☆☆ (1/5)
Quality: ★★★★☆ (4/5)
Staffing: ★★★★☆ (4/5)
|
|
NursingHomeGrade Score
|
33/100 |
Loaded into NursingHomeGrade on August 7, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.
Staffing Compared With State and National Levels
| This facility | 0.68 hrs |
|---|---|
| MN median | 0.96 hrs |
| National average | 0.69 hrs |
Registered nurse turnover: 46.2% · Total nursing staff turnover: 29.2%
Staffing figures are the values CMS published in its file processed July 1, 2026, drawn from payroll-based journal reporting.
Inspection Records Covered
- Most recent standard health survey: March 27, 2025.
- Citations shown below span 3 recorded inspection cycles.
- Survey dates on file range from March 9, 2023 to March 13, 2026.
Source records: CMS Care Compare profile for provider 245203 ↗ · the federal files we load and when.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
5 immediate jeopardy, 1 actual harm issues found among 61 total deficiencies. 61 corrected.
Most recent inspection (March 27, 2025)
E
Potential harm — pattern
F0921
Status: Corrected
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
J
Immediate jeopardy — isolated
F0600
Status: Corrected
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2025
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0758
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
J
Immediate jeopardy — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2026
D
Potential harm — isolated
F0692
Status: Corrected
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2026
G
Actual harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Past Non-Compliance
E
Potential harm — pattern
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0676
Status: Corrected
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0685
Status: Corrected
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0687
Status: Corrected
Provide appropriate foot care.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0688
Status: Corrected
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0740
Status: Corrected
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0638
Status: Corrected
Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0645
Status: Corrected
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
J
Immediate jeopardy — isolated
F0578
Status: Corrected
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.
Resident Rights Deficiencies — Past Non-Compliance
D
Potential harm — isolated
F0576
Status: Corrected
Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
B
No harm — pattern
F0583
Status: Corrected
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
Inspection cycle 2 (August 12, 2024)
D
Potential harm — isolated
F0949
Status: Corrected
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Administration Deficiencies — Deficient, Provider has date of correction, corrected September 4, 2024
B
No harm — pattern
F0941
Status: Corrected
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Administration Deficiencies — Deficient, Provider has date of correction, corrected September 4, 2024
B
No harm — pattern
F0944
Status: Corrected
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Administration Deficiencies — Deficient, Provider has date of correction, corrected September 4, 2024
D
Potential harm — isolated
F0914
Status: Corrected
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected September 4, 2024
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2025
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
D
Potential harm — isolated
F0883
Status: Corrected
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
C
No harm — widespread
F0732
Status: Corrected
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
F
Potential harm — widespread
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2025
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2025
J
Immediate jeopardy — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected June 10, 2025
D
Potential harm — isolated
F0742
Status: Corrected
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2025
D
Potential harm — isolated
F0692
Status: Corrected
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 29, 2025
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 3, 2025
L
Immediate jeopardy — widespread
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 4, 2024
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
D
Potential harm — isolated
F0693
Status: Corrected
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
D
Potential harm — isolated
F0699
Status: Corrected
Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
D
Potential harm — isolated
F0657
Status: Corrected
Develop 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 Planning Deficiencies — Deficient, Provider has date of correction, corrected July 18, 2025
D
Potential harm — isolated
F0554
Status: Corrected
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
D
Potential harm — isolated
F0584
Status: Corrected
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 14, 2024
Inspection cycle 3 (March 9, 2023)
F
Potential harm — widespread
F0921
Status: Corrected
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0757
Status: Corrected
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0758
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 8, 2024
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0691
Status: Corrected
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0742
Status: Corrected
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
E
Potential harm — pattern
F0645
Status: Corrected
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0655
Status: Corrected
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0656
Status: Corrected
Develop 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 Planning Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0553
Status: Corrected
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
D
Potential harm — isolated
F0580
Status: Corrected
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2023
Fines and Enforcement Actions
Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.
| Date | Action | Amount or length |
|---|---|---|
| February 27, 2026 | Fine | $16,720 |
| August 12, 2024 | Fine | $35,260 |
2 fines totalling $51,980.
Source: CMS Penalties file (dataset g6vv-u9sr).
Ownership and Contact Information
- Facility name
- Villas At Bryn Mawr LLC
- Address
- 275 PENN AVENUE NORTH, MINNEAPOLIS, MN 55405
- Phone
- (612) 377-4723
- Provider number (CCN)
- 245203
- Ownership type
- For profit - Limited Liability company
- Operator
- MONARCH HEALTHCARE OPERATING XII · 11 facilities
- Medicare/Medicaid certified since
- October 1, 1978
- Official record
- CMS Care Compare profile ↗
- Details verified against CMS data dated
- July 1, 2026
The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.
How We Stay Independent
NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.
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Sources and Methodology
- CMS Provider Information (file processed July 1, 2026) — ratings, staffing, ownership, certification and contact details. Dataset 4pq5-n9py ↗
- CMS Health Deficiencies — inspection citations, scope and severity, correction status. Dataset r5ix-sfxw ↗
- CMS Penalties — fines and payment denials with the dates CMS recorded them. Dataset g6vv-u9sr ↗
- CMS Ownership — owning and managing organisations. Dataset y2hd-n93e ↗
The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.
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