Cycle 1
Health 2025-02-27 · Fire 2025-02-27
11 health deficiencies
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Saint Paul, MN
Ebenezer Integrated Care & Rehab
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
45 West 10th Street, Saint Paul, MN
(651) 326-4900
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ebenezer Senior Living
Operator or chain grouping
Approved since
1991-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
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
2.13
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.29
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.67
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.67
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.64
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.39
CMS adjusted RN staffing hours
Adjusted total hours
5.94
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,124
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0060
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.58
Performance 18.38% · Measure score 6.58 · Achievement 6.58 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.10
Performance 6.91% · Measure score 3.10 · Achievement 3.10 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.33
Baseline 40.82% · Performance 45.98% · Measure score 4.33 · Achievement 4.33 · Improvement 0
Adjusted total nurse staffing
6.64
Baseline 4.28 hours · Performance 4.97 hours · Measure score 6.64 · Achievement 6.64 · Improvement 4.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 6.77% |
| Discharge to community | 43.79% |
50.57%
6.8 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 34.21% · Lower 95% interval 29.1% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 71 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 20.37% |
53.69%
33.3 pts worse
|
Numerator 11 · Denominator 54 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 18 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 72 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 145 |
| Staff flu vaccination coverage | 56.41% |
42%
14.4 pts better
|
Numerator 66 · Denominator 117 |
| Discharge function score | 40.74% |
56.45%
15.7 pts worse
|
Numerator 22 · Denominator 54 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 38 · Denominator 40 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.88% |
25.2%
9.7 pts better
|
Numerator 15 · 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 | 95.8% |
97.3%
1.5 pts worse
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 90.2% · Q3 100.0% · Q4 100.0% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
96.1%
2.1 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.9%
0.3 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.6% · Q4 9.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.8% |
4.3%
7.5 pts worse
|
11.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 17.1% · Q3 12.1% · Q4 11.1% · 4Q avg 11.8% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
4.1%
0.8 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 7.5% · Q3 2.9% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
12.4%
3.1 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.0% · Q3 14.3% · Q4 16.7% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 39.4% |
17.5%
21.9 pts worse
|
16.7%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.4% · Q2 40.7% · Q3 42.3% · Q4 33.3% · 4Q avg 39.4% · 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 | 26.8% |
22.5%
4.3 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.2% |
18.6%
4.6 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 16.7% · Q3 29.0% · Q4 18.2% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.3%
0.6 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.6% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
24.8%
1.3 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 24.6% · Q3 35.9% · Q4 24.9% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.4%
0.4 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.8% · Q3 2.5% · Q4 9.7% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.5% |
88.6%
4.1 pts worse
|
81.7%
2.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.7% · Q2 85.3% · Q3 88.4% · Q4 79.8% · 4Q avg 84.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.1% |
14.0%
4.1 pts worse
|
12.0%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 21.0% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.9%
1.2 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.9% · Q3 4.4% · Q4 3.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.4% |
82.7%
31.3 pts worse
|
79.7%
28.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
23.1%
5.4 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 19.4% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-27
F · Potential for more than minimal harm
2024-03-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-03-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-03-21
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-05-10
F · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-23
C · Minimal harm
2022-10-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-23
Inspection history
Recent health citations
G · Actual harm
2025-12-05
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 2025-11-11
D · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-17
J · Immediate jeopardy
2025-02-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-27
D · Potential for more than minimal harm
2024-10-01
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 2024-11-01
D · Potential for more than minimal harm
2024-07-25
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 2024-09-02
D · Potential for more than minimal harm
2024-07-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-03-21
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-03-06
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-04-19
D · Potential for more than minimal harm
2022-10-27
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-10-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-10-27
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-10-27
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-12-09
C · Minimal harm
2022-10-27
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 2022-12-09
Penalties and ownership
What sits behind the stars
$26,685
2025-02-27
Fine
Fine · fine $26,685
Fine
Ownership
Bell, Brittany
W-2 Managing Employee · Individual
Carlson-Weinberg, Susan
Corporate Director · Individual
Digiacomo, Nicoletta
W-2 Managing Employee · Individual
Ebenezer Society
Operational/Managerial Control · Organization
Faust, Kim
Corporate Director · Individual
Gruman, Robb
Corporate Director · Individual
Hereford, James
Corporate Director · Individual
Hokr, Thomas
Corporate Director · Individual
Jacobson, Carolyn
Corporate Director · Individual
Johnson, Brenda
W-2 Managing Employee · Individual
Koehnen, Amy
W-2 Managing Employee · Individual
Lundberg, Jonathan
Corporate Officer · Individual
Lundberg, Jonathan
W-2 Managing Employee · Individual
Piper, Kenneth
Corporate Director · Individual
Walker, Robert
Corporate Director · Individual
Willett, Todd
Corporate Officer · Individual
Wordelman, Scott
Corporate Director · Individual
Nearby options
Other facilities in reach
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Capitol View Transitional Care Center
Saint Paul, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Little Sisters Of The Poor
Saint Paul, MN
4-star overall rating with 2-star inspections with $17,584 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Villas At St Paul
Saint Paul, MN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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