12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Minneapolis, MN
2-star overall rating with 3-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
3700 Cedar Lake Avenue, Minneapolis, MN
(612) 920-2030
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
110
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ebenezer Senior Living
Operator or chain grouping
Approved since
1987-04-01
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
RN hours / resident day
0.97
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
1,591
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0105
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.90
Baseline 22.34% · Performance 20.53% · Measure score 2.90 · Achievement 1.94 · Improvement 2.90
Healthcare-associated infections
6.85
Baseline 4.34% · Performance 5.79% · Measure score 6.85 · Achievement 6.85 · Improvement 0
Total nurse turnover
8.40
Performance 29.36% · Measure score 8.40 · Achievement 8.40 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.04
Baseline 4.22 hours · Performance 4.23 hours · Measure score 4.04 · Achievement 4.04 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 8.88% · Lower 95% interval 7.68% |
| Discharge to community | 47.38% |
50.57%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 42.01% · Lower 95% interval 40.15% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.17% |
95.27%
1.9 pts better
|
Numerator 103 · Denominator 106 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 106 |
| Discharge self-care score | 36.36% |
53.69%
17.3 pts worse
|
Numerator 32 · Denominator 88 |
| Discharge mobility score | 35.23% |
50.94%
15.7 pts worse
|
Numerator 31 · Denominator 88 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 106 · Adjusted rate 1.99% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 2.94% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 1.49% |
8.2%
6.7 pts worse
|
Numerator 4 · Denominator 269 |
| Staff flu vaccination coverage | 46.31% |
42%
4.3 pts better
|
Numerator 94 · Denominator 203 |
| Discharge function score | 47.73% |
56.45%
8.7 pts worse
|
Numerator 42 · Denominator 88 |
| Transfer of health information to provider | 85.71% |
95.95%
10.2 pts worse
|
Numerator 18 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 55 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 51.92% |
25.2%
26.7 pts better
|
Numerator 27 · Denominator 52 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
97.3%
4.5 pts worse
|
93.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 89.8% · Q3 95.3% · Q4 100.0% · 4Q avg 92.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
96.1%
2.9 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.9%
0.5 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.4% · Q3 2.4% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
4.3%
1.6 pts worse
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.8% · Q3 8.5% · Q4 8.6% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
4.1%
0.2 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.2% · Q3 4.3% · Q4 3.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
12.4%
5 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 4.2% · Q3 5.6% · Q4 7.6% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
17.5%
9.3 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.5% · Q3 8.2% · Q4 8.8% · 4Q avg 8.2% · 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 | 33.8% |
22.5%
11.3 pts worse
|
16.3%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 39.4% · Q4 34.3% · 4Q avg 33.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
18.6%
0.8 pts better
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 22.7% · Q3 19.0% · Q4 15.0% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.3%
1.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.3% · Q3 2.4% · Q4 1.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
24.8%
0.8 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 23.0% · Q3 23.7% · Q4 21.6% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.4%
About the same
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.5% · Q3 8.1% · Q4 5.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
88.6%
7 pts worse
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 82.9% · Q3 79.8% · Q4 77.0% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
14.0%
6.4 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.9%
2 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.7% · Q3 2.7% · Q4 2.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.6% |
82.7%
5.1 pts worse
|
79.7%
2.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
23.1%
1.7 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 18.6% · Expected 20.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-28
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-02-28
Fire Safety
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.
Corrected 2026-02-28
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 2026-02-28
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-02-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-28
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-31
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-31
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-31
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-31
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-01-31
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-29
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-29
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-29
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-02-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-29
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-31
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-21
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-02-29
Inspection history
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-28
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-28
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-28
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-02-28
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2026-02-28
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-28
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2026-02-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-23
Health
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.
Corrected 2024-12-23
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-23
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-23
Health
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.
Corrected 2024-12-23
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-23
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-12-23
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-05
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-21
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-21
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 2024-02-21
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-02-21
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-21
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-21
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-04-24
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-24
Penalties and ownership
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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