Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
VILLAS AT BRYN MAWR LLC
MINNEAPOLIS, MN · 105 certified beds · Last Life Safety survey June 17, 2026
CMS Certification Number 245203 · first certified October 1978
Ownership
Operated by MONARCH HEALTHCARE MANAGEMENT · For profit - Corporation
- Ownership changed January 1, 2023 (change of ownership)from VILLA AT BRYN MAWR LLC
Position within MN
29 citations — more than 96% of the 338 certified nursing homes in MN. Compared within MN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 8 months from now. This facility’s last Life Safety survey was June 2026. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 29 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0924 Put firmly secured handrails on each side of hallways.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 2, 2024 | 8 |
| March 27, 2025 | 8 |
| June 17, 2026 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-06-17 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2026-06-17 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2026-06-17 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2026-06-17 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 2 | 2025-03-27 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-06-17 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-03-27 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2026-06-17 |
What the citations cover
- Smoke Deficiencies 13
- Egress Deficiencies 5
- Miscellaneous Deficiencies 3
- Services Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Egress Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 17, 2026 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has plan of correction (July 29, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has plan of correction (July 29, 2026) |
March 27, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 29, 2025) |
May 2, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 14, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 14, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 14, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.