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The Villa At Bryn Mawr

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About The Villa At Bryn Mawr

General Information

Legal Business NameVilla At Bryn Mawr LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareOctober 1, 1978 (39 years)
Capacity120
Residents111
Percent Occupied93%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for The Villa At Bryn Mawr

The Villa At Bryn Mawr
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Minnesota Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

August 5, 2016 - 9 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
DFewPotential for HarmHealth InspectionGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
DFewPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmHealth InspectionAllow residents to self-administer drugs if determined safe.

May 7, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CManyPotential for Minimal HarmHealth InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .

June 13, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
ESomePotential for HarmHealth InspectionMake sure that a working call system is available in each resident's room or bathroom and bathing area.
ESomePotential for HarmHealth Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmHealth InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmHealth InspectionProvide or obtain dental services for each resident.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmHealth InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.
DFewPotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmHealth InspectionGive residents a notice of rights, rules, services and charges.
DFewPotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmHealth InspectionMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of The Villa At Bryn Mawr require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

1hr 35min
1hr 50min
ReportedExpected
CNA
40min
30min
ReportedExpected
LPN
30min
50min
ReportedExpected
RN
2hr 50min
3hr 10min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

96.4%
87.2%
87.3%
87.3%
96.5%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
58.9%
67.0%
69.8%
92.6%
95.0%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
20.6%
30.2%
27.3%
20.0%
50.5%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of low risk long-stay residents who lose control of their bowels or bladder
27.6%
31.8%
32.6%
21.7%
13.7%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents who received an antianxiety or hypnotic medication
15.2%
11.0%
25.4%
23.6%
17.1%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents whose ability to move independently worsened
36.0%
30.2%
25.0%
40.0%
13.7%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents who received an antipsychotic medication
14.6%
10.0%
19.1%
15.4%
14.7%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents whose need for help with daily activities has increased
20.4%
12.7%
25.9%
1.9%
10.8%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents who self-report moderate to severe pain
12.0%
11.8%
6.3%
3.2%
7.1%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents who lose too much weight
6.5%
15.4%
7.1%
6.5%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of high risk long-stay residents with pressure ulcers
10.2%
2.6%
6.2%
6.4%
4.6%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents who have depressive symptoms
2.0%
1.1%
0.0%
1.1%
3.9%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents with a urinary tract infection
3.7%
4.3%
4.2%
4.3%
4.2%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents experiencing one or more falls with major injury
1.1%
1.1%
2.0%
4.6%
2.8%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.2%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

29.4%
35.3%
23.9%
35.7%
83.6%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
47.7%
29.4%
29.4%
29.4%
81.4%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
73.5%
Q4 2015Q1 2016Q2 2016Q3 2016MN
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
-
-
-
-
22.4%
Q4 2015Q1 2016Q2 2016Q3 2016MN
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
-
-
4.8%
4.0%
1.8%
Q4 2015Q1 2016Q2 2016Q3 2016MN
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
0.0%
0.0%
2.0%
1.3%
Q4 2015Q1 2016Q2 2016Q3 2016MN
Percentage of short-stay residents with pressure ulcers that are new or worsened