Cycle 1
Health 2025-02-06 · Fire 2025-02-06
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Saint Paul, MN
Cerenity Marian Of St Paul LLC
3-star overall rating with 2-star inspections with $151,799 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
200 Earl Street, Saint Paul, MN
(651) 793-2100
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
4.58
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,262
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.85
Baseline 18.52% · Performance 21.04% · Measure score 0.85 · Achievement 0.85 · Improvement 0
Healthcare-associated infections
2.37
Baseline 5.96% · Performance 7.13% · Measure score 2.37 · Achievement 2.37 · Improvement 0
Total nurse turnover
2.07
Baseline 68.85% · Performance 57.55% · Measure score 2.07 · Achievement 1.5 · Improvement 2.07
Adjusted total nurse staffing
4.42
Baseline 4.34 hours · Performance 4.33 hours · Measure score 4.42 · Achievement 4.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 12.82% · Lower 95% interval 7.77% |
| Discharge to community | 62.69% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 117 · Observed rate 58.97% · Lower 95% interval 52.69% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 92.13% |
95.27%
3.1 pts worse
|
Numerator 82 · Denominator 89 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 89 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 32 · Denominator 60 |
| Discharge mobility score | 41.67% |
50.94%
9.3 pts worse
|
Numerator 25 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 89 · Adjusted rate 1.46% |
| Healthcare-associated infections requiring hospitalization | 7.13% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 29.73% |
8.2%
21.5 pts better
|
Numerator 44 · Denominator 148 |
| Staff flu vaccination coverage | 49.72% |
42%
7.7 pts better
|
Numerator 88 · Denominator 177 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 30 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 98.21% |
96.28%
1.9 pts better
|
Numerator 55 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 53.49% |
25.2%
28.3 pts better
|
Numerator 23 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
97.3%
1.8 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.7% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
96.1%
2.2 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.9%
0.8 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 3.3% · Q4 5.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.3%
1.3 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 5.7% · Q4 3.5% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
4.1%
2.6 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 10.9% · Q3 2.4% · Q4 10.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.8% |
12.4%
6.6 pts better
|
19.6%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.5% · Q3 4.2% · Q4 8.2% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.2% |
17.5%
8.3 pts better
|
16.7%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 8.6% · Q3 9.8% · Q4 9.1% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.3% |
22.5%
1.8 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 24.1% · Q4 11.1% · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 38.2% |
18.6%
19.6 pts worse
|
14.9%
23.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.8% · Q2 37.2% · Q3 44.2% · Q4 22.7% · 4Q avg 38.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.6%
1.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
24.8%
4.5 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 29.0% · Q3 28.6% · Q4 33.8% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.4%
3.3 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 11.8% · Q3 8.7% · Q4 5.2% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
88.6%
3.2 pts better
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 90.0% · Q3 91.8% · Q4 93.9% · 4Q avg 91.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
14.0%
1.7 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.9%
1.7 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.5% |
82.7%
0.2 pts worse
|
79.7%
2.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
23.1%
3.2 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 22.6% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-21 · Fire 2023-09-21
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-02-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-02-06
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2025-03-10
F · Potential for more than minimal harm
2024-04-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-16
F · Potential for more than minimal harm
2024-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-16
F · Potential for more than minimal harm
2024-04-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-16
F · Potential for more than minimal harm
2023-09-21
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-11-07
F · Potential for more than minimal harm
2023-09-21
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-11-07
F · Potential for more than minimal harm
2023-09-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-07
Inspection history
Recent health citations
G · Actual harm
2025-02-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-02-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-04
J · Immediate jeopardy
2024-08-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-04-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-29
E · Potential for more than minimal harm
2023-09-21
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-07
E · Potential for more than minimal harm
2023-09-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-07
F · Potential for more than minimal harm
2023-04-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-16
Penalties and ownership
What sits behind the stars
$59,675
2025-02-06
Fine
Fine · fine $59,675
Fine
$92,124
2024-08-16
Fine
Fine · fine $92,124
Fine
Ownership
Cerenity Senior Care
5% Or Greater Direct Ownership Interest · Organization
Benedictine Health System
5% Or Greater Indirect Ownership Interest · Organization
Fairview Bethesda Hospital
5% Or Greater Indirect Ownership Interest · Organization
Benedictine Health System
Operational/Managerial Control · Organization
Bergien, Tricia
Corporate Officer · Individual
Bruhn, Jennifer
Corporate Officer · Individual
Carley, Gerald
Corporate Director · Individual
Foussard, William
Corporate Director · Individual
Grzywinski, Joan
Corporate Director · Individual
Ksepka, Dawn
Corporate Director · Individual
Lundberg, Jonathan
Corporate Director · Individual
Rymanowski, Kevin
Corporate Officer · Individual
Schumacher, Kay
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Cerenity Care Center on Humboldt
Saint Paul, MN
1-star overall rating with 1-star inspections with $105,767 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Capitol View Transitional Care Center
Saint Paul, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Ebenezer Integrated Care & Rehab
Saint Paul, MN
3-star overall rating with 2-star inspections with $26,685 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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