Cycle 1
Health 2025-04-16 · Fire 2025-04-16
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Wyoming, MN
Meadows On Fairview
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
25565 Fairview Avenue, Wyoming, MN
(651) 466-1300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
14
Certified beds
Average residents
12
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ebenezer Senior Living
Operator or chain grouping
Approved since
2014-12-23
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
3.77
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.66
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
8.75
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
5.08
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
7.19
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
2.18
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.46
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
3.54
CMS adjusted RN staffing hours
Adjusted total hours
8.21
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,439
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.70
Composite VBP score used to determine payment impact.
Payment multiplier
1.0118
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.33
Baseline 17.40% · Performance 20.82% · Measure score 1.33 · Achievement 1.33 · Improvement 0
Healthcare-associated infections
6.63
Baseline 4.82% · Performance 5.85% · Measure score 6.63 · Achievement 6.63 · Improvement 0
Total nurse turnover
9.06
Performance 26.67% · Measure score 9.06 · Achievement 9.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 7.41% · Lower 95% interval 6.54% |
| Discharge to community | 62.75% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 106 · Observed rate 64.15% · Lower 95% interval 53.87% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.87% |
95.27%
0.4 pts worse
|
Numerator 74 · Denominator 78 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 78 |
| Discharge self-care score | 69.57% |
53.69%
15.9 pts better
|
Numerator 48 · Denominator 69 |
| Discharge mobility score | 65.22% |
50.94%
14.3 pts better
|
Numerator 45 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 1.28% |
2.29%
1 pts better
|
Numerator 1 · Denominator 78 · Adjusted rate 1.82% |
| Healthcare-associated infections requiring hospitalization | 5.85% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 1.64% · Lower 95% interval 2.84% |
| Staff COVID-19 vaccination coverage | 1.54% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 65 |
| Staff flu vaccination coverage | 40% |
42%
2 pts worse
|
Numerator 20 · Denominator 50 |
| Discharge function score | 59.42% |
56.45%
3 pts better
|
Numerator 41 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 65 · Denominator 65 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 12 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
88.6%
7.9 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 97.4% · Q3 96.0% · Q4 95.3% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
14.0%
5.8 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.2% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.9%
0.9 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.5% |
82.7%
6.2 pts worse
|
79.7%
3.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
23.1%
6 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 13.0% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-16
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-07-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-06
F · Potential for more than minimal harm
2024-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-01
F · Potential for more than minimal harm
2023-04-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-10
C · Minimal harm
2023-04-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-09
C · Minimal harm
2023-04-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-09
C · Minimal harm
2023-04-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-09
C · Minimal harm
2023-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-23
D · Potential for more than minimal harm
2024-07-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-20
Penalties and ownership
What sits behind the stars
Ownership
Ebenezer Society
5% Or Greater Direct Ownership Interest · Organization
Bell, Brittany
W-2 Managing Employee · Individual
Carlson-Weinberg, Susan
Corporate Director · Individual
Ebenezer Management Services Inc
Operational/Managerial Control · Organization
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
Howard, Richard
Corporate Director · Individual
Jacobson, Carolyn
Corporate Director · Individual
Lundberg, Jonathan
Corporate Officer · Individual
Lundberg, Jonathan
W-2 Managing Employee · Individual
Mccray, David
W-2 Managing Employee · Individual
Runck, Carl
Corporate Director · Individual
Willett, Todd
Corporate Officer · Individual
Willett, Todd
W-2 Managing Employee · Individual
Wordelman, Scott
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Birchwood Health Care Center
Forest Lake, MN
2-star overall rating with 1-star inspections with $132,781 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Parmly on the Lake LLC
Chisago City, MN
3-star overall rating with 3-star inspections with $8,193 in total fines with 7 recent health deficiencies
#3
Ecumen North Branch
North Branch, MN
3-star overall rating with 3-star inspections with 3 recent health deficiencies
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