Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ebenezer Ridges Geriatric Care Center during CMS and state inspections, most recent first.
The facility failed to ensure routine personal hygiene, specifically showers, for four residents dependent on staff for care. Residents experienced missed showers without documentation of offers or refusals, despite being scheduled for specific days. Interviews revealed dissatisfaction and the importance of personal hygiene for residents' well-being. The facility's policy required documentation of showers in the EHR, which was not adhered to, leading to the deficiency.
A resident with impaired cognition and specific bathing preferences was not accommodated by the facility, which assigned shower schedules based on room numbers rather than individual preferences. Despite the resident's care plan indicating that their preferences should be followed, staff confirmed that shower times were not reflective of the resident's wishes, and the facility lacked a policy on accommodating such preferences.
A resident with a history of stroke and left upper extremity weakness was inaccurately coded in the MDS as having no impairment. The resident's left arm was immobilized in a sling, but the care plan lacked details on its use. Facility staff, including the rehabilitation supervisor and director of nursing, acknowledged the coding error and the absence of proper assessment documentation.
A resident admitted with a fracture and other conditions did not receive a care conference within the required 21 days. Despite discharge planning being noted, there was no evidence of a care conference in the progress notes. Facility staff confirmed the oversight, acknowledging the missed care conference, which is expected within the first two weeks of admission.
A resident receiving hospice care was prescribed PRN haloperidol without an end date, leading to its use beyond 14 days without re-evaluation. The facility's policy required PRN psychotropic medications to be limited to 14 days unless extended with documented rationale, which was not adhered to in this case.
The facility failed to implement enhanced barrier precautions (EBP) for two residents, leading to a deficiency in infection control. Staff did not consistently use gowns and gloves during high-contact activities, despite CDC guidelines and posted EBP signs. Observations revealed that staff lacked understanding of EBP requirements, resulting in non-compliance during care for residents with indwelling devices and wounds.
A resident, who was cognitively intact and required assistance with daily activities, was taken to therapy without proper incontinence protection, resulting in urination on herself and her wheelchair in front of others. The care plan lacked clear instructions for incontinence management when out of bed, and staff interviews revealed a lack of communication and understanding of responsibilities, leading to a failure in maintaining the resident's dignity.
The facility failed to systematically assess and evaluate fluid status for two residents on fluid restrictions, leading to inadequate monitoring of interventions. One resident was hospitalized with severe sepsis, and both residents expressed confusion about fluid management. Staff interviews revealed uncertainty about responsibility for monitoring fluid restrictions, indicating a systemic issue in fluid management.
The facility failed to disinfect a vital signs machine between resident uses and placed a resident on incorrect isolation precautions. An LPN used the machine on a resident under contact precautions and then on another resident without sanitizing it. The resident was suspected of having COVID-19, requiring droplet precautions, but was placed on contact precautions instead. The facility was experiencing a COVID-19 outbreak, and staff were uncertain about the correct precautions for the resident.
Failure to Ensure Routine Personal Hygiene for Residents
Penalty
Summary
The facility failed to ensure routine personal hygiene, specifically showers, was completed for four residents who were dependent on staff for their care. Resident R89, admitted to the facility's transitional care unit (TCU) with severe cognitive impairment and other medical conditions, was scheduled for showers on Saturday evenings. However, documentation indicated a missed shower on 11/9/24, with no record of refusal or alternative arrangements. Interviews with R89 and their family member revealed dissatisfaction with the lack of regular showers, emphasizing the importance of personal hygiene for the resident's well-being. Resident R159, with impaired cognition and requiring substantial assistance, was also affected by the facility's failure to document showers or refusals. Despite being scheduled for showers on Friday evenings, there was no evidence of showers being offered or refused since admission. The nursing staff acknowledged the lack of documentation and expressed concern over the resident not receiving showers as expected. Similarly, Resident R162, with moderately impaired cognition and requiring assistance, missed scheduled showers on 11/1/24 and 11/8/24, with no documentation of offers or refusals. The facility's director of nursing confirmed the issue of missed showers and the importance of documenting such events. Resident R103, with intact cognition but dependent on staff for showers, also experienced a missed shower on 11/16/24, with no record of refusal or alternative arrangements. The facility's policy required documentation of showers in the electronic health record, which was not adhered to, leading to the deficiency.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing preferences of a resident, identified as R159, who was admitted with impaired cognition and required substantial assistance for personal care activities. The resident's care plan explicitly stated that their preferences should be followed. However, the facility assigned shower schedules based on room numbers rather than individual preferences. R159 expressed a preference for morning showers due to fatigue after physical therapy sessions, but was assigned to shower on Friday evenings, contrary to their wishes. Interviews with staff, including nursing assistants and the director of nursing, confirmed that shower schedules were determined by room assignments rather than resident preferences. The director of nursing acknowledged that the current system did not reflect R159's preferences and agreed that it would be more appropriate for the resident to shower in the morning. Despite requests, the facility did not provide a policy on choices and preferences, indicating a lack of formal guidance on accommodating resident preferences.
Inaccurate MDS Coding for Resident's Upper Body Impairment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect upper body impairment for a resident, identified as R162, who was reviewed for MDS accuracy. R162 was admitted to the facility's transitional care unit with moderately impaired cognition and required assistance with various activities of daily living. The MDS section GG0115, which pertains to functional limitation in range of motion, incorrectly identified R162 as having no impairment of upper and lower extremities, despite the resident's medical history of a stroke and observed left upper extremity weakness. Observations and interviews revealed that R162 had a left arm immobilized in a sling due to flaccid left hemiparesis from a prior stroke. The resident confirmed the necessity of the sling to prevent her left arm from flopping down due to lack of control or feeling. However, the care plan, orders, and nursing assistant care sheet and Kardex did not mention an assessment for the use of the sling, including its purpose, who was responsible for applying and removing it, and when it should be done. Interviews with facility staff, including the rehabilitation supervisor, nursing assistant, TCU nurse manager, and director of Resident Assessment Instrument (RAI)/MDS, confirmed the oversight in coding the MDS accurately. The rehabilitation supervisor acknowledged the responsibility of the therapy department to assess the use and appropriateness of the sling, but was unable to determine if such an assessment was conducted. The director of nursing and other staff members recognized the inaccuracy in the MDS coding, noting that the resident's impairment was not reflected correctly in the documentation.
Failure to Conduct Timely Care Conference for Resident
Penalty
Summary
The facility failed to conduct a care conference for a resident, identified as R103, within the required timeframe following admission. R103 was admitted on 10/29/24 with diagnoses including a displaced bicondylar fracture of the left tibia, muscle weakness, and an infection related to orthopedic implants. Despite the requirement to hold a care conference within 21 days of admission, no such conference was held for R103, as confirmed by the resident and facility staff. The resident's care plan, printed on 11/18/24, indicated discharge planning, but there was no evidence of a care conference or planning for one in the progress notes from 10/29/24 to 11/21/24. Interviews with facility staff, including a nurse manager and social worker, confirmed that a care conference had not been conducted for R103 since admission. The social worker acknowledged that the care conference was missed and that it is expected to occur within the first week or two of admission, but no later than 21 days. The Director of Nursing also stated that the expectation is for a care conference to be held within 21 days of admission. The facility's policy, revised in 10/18, mandates care conferences upon admission, quarterly, with significant changes, and as needed, but this was not adhered to in R103's case.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that as-needed (PRN) antipsychotic medications were limited to 14 days of use or re-evaluated by a medical provider for a resident receiving hospice care. The resident, who had moderately impaired cognition and was diagnosed with dementia, anxiety, and depression, was prescribed two milligrams of haloperidol three times a day as needed for agitation or nausea. The order, initiated by a hospice provider, did not include an end date, and the resident received the medication over ten times within the review period without a re-evaluation by a medical provider. Interviews with facility staff, including the unit nurse manager, the resident's primary care nurse practitioner, and the hospice nurse, confirmed that the PRN haloperidol order had been active for longer than 14 days without reassessment or renewal. The facility's Psychopharmacologic Drug Use policy required PRN psychotropic medications to be limited to 14 days unless extended by the prescribing practitioner with documented rationale, which was not followed in this case. The director of nursing also confirmed the lack of a stop date or renewal for the medication order.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow enhanced barrier precautions (EBP) for two residents, leading to a deficiency in infection prevention and control. The Centers for Disease Control and Prevention (CDC) guidelines indicate that EBP should be used to reduce the transmission of multidrug-resistant organisms (MDROs) by using gowns and gloves during high-contact resident care activities. However, observations and interviews revealed that staff did not consistently use the required personal protective equipment (PPE) when providing care to residents with indwelling medical devices or wounds. For one resident, who had severely impaired cognition and required total assistance with care activities, staff were observed not using gowns while repositioning the resident in bed, despite the presence of a feeding tube. The staff development director incorrectly advised podiatry staff that EBP was not necessary for foot care, demonstrating a misunderstanding of the guidelines. Interviews with the director of nursing and the infection preventionist confirmed that staff were expected to use PPE during resident transfers and other high-contact activities, but this was not consistently practiced. Another resident, who had moderate cognitive impairment and a pressure area, was also not provided with appropriate EBP. Nursing assistants were observed providing personal care and transferring the resident without wearing gowns, despite the presence of a wound and posted EBP signs. Interviews with the nursing assistants revealed a lack of understanding of EBP requirements, as they did not recognize the need to wear gowns during these activities. The licensed practical nurse caring for the resident expressed concern about the potential spread of pathogens due to non-compliance with EBP guidelines.
Failure to Maintain Resident Dignity During Therapy
Penalty
Summary
The facility failed to promote dignity and respect for a resident who was cognitively intact and required maximum assistance with toileting hygiene, showering, and dressing. The resident, who had diagnoses including cirrhosis of the liver, acute respiratory failure with hypoxia, and type 2 diabetes mellitus with neuropathy, was frequently incontinent of urine and bowel. The care plan indicated that the resident should not wear an incontinent brief while in bed to prevent skin impairment, but it did not specify what should be worn for incontinence protection when out of bed. During a therapy session, the resident was not properly dressed and urinated on herself, her wheelchair, and the floor in the presence of other residents and staff, leading to feelings of humiliation. Interviews with staff revealed a lack of communication and understanding of responsibilities regarding the resident's attire and incontinence management. The occupational therapy assistant and physical therapy assistant noted that the resident was often taken to therapy without an incontinent brief, and towels were used instead, which were not effective. The registered nurses and director of nursing were unaware of the incident and the use of towels, indicating a breakdown in communication and adherence to the facility's policy on dignity. The facility's policy emphasized maintaining residents' dignity by ensuring they are dressed appropriately, which was not followed in this case.
Failure to Monitor Fluid Restrictions for Residents
Penalty
Summary
The facility failed to implement a systematic approach to assess and evaluate the fluid status of residents, specifically for two residents who were on a daily fluid restriction. The facility documented the intake but did not have a system in place to evaluate the total daily fluid intake to determine adequacy or if the provider required notification. This deficiency was identified through interviews and record reviews, revealing that the facility did not adequately monitor the effectiveness of interventions for these residents. One resident, who had a fluid restriction of 1200 milliliters per day, had nursing progress notes that lacked documentation regarding the fluid restriction, except for a single entry. The care plan did not indicate the fluid restriction, and the electronic treatment record showed inconsistencies in documenting fluid intake. This resident was admitted to the hospital with severe sepsis and other complications, and she expressed confusion about how the facility managed her fluid restrictions, indicating a lack of communication and understanding. Another resident also had a fluid restriction order, but the nursing staff did not document the amount of fluid consumed during shifts, only checking boxes to indicate the restriction was administered. The care plan did not mention fluid restrictions, and the resident was uncertain about how the facility monitored her fluid intake. Interviews with staff, including the LPN, RN, assistant dietary manager, and the corporate registered dietician, revealed uncertainty and lack of clarity about who was responsible for monitoring and managing fluid restrictions, highlighting a systemic issue in the facility's approach to fluid management.
Failure to Disinfect Equipment and Incorrect Isolation Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the disinfection of medical equipment between resident uses. An LPN was observed taking vital signs of a resident on contact precautions without disinfecting the vital signs machine afterward. This machine was then used on another resident without being sanitized. The LPN admitted to usually disinfecting the equipment but failed to do so due to a busy morning. Additionally, the facility placed the resident on incorrect isolation precautions, as the resident was suspected of having COVID-19, which requires droplet precautions, but was instead placed on contact precautions. The facility was experiencing a COVID-19 outbreak with 11 cases across two units. The Director of Nursing and the Infection Preventionist were uncertain about the specific precautions the resident was under, and the resident's care plan did not indicate the need for isolation precautions. The facility's policy on transmission and isolation precautions was not followed, as equipment was not disinfected between uses, and the resident was not placed under the correct precautions for suspected COVID-19.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burnsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Valley Village Health Care Center | 3.2 mi | ★★★★★ | 1 | 0 |
| Minnesota Masonic Home Care Center | 4.8 mi | ★★★★★ | 11 | 0 |
| Martin Luther Care Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Presbyterian Homes Of Bloomington | 5.2 mi | ★★★★★ | 1 | 0 |
| The Estates At Bloomington Llc | 5.8 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.