Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Edenbrook Of St Cloud during CMS and state inspections, most recent first.
The facility failed to serve food at a palatable temperature, affecting all residents. Observations and interviews revealed that meals were often cold, with some items undercooked or overcooked. Food was left on carts for extended periods, and staff did not consistently check temperatures during serving. The steam table had issues maintaining adequate temperatures, and the facility's policy for safe food temperatures was not followed, leading to a deficiency.
Two residents experienced neglect in a facility, with one resident left with full urinals and another missing scheduled baths. Despite needing assistance due to cognitive and mobility impairments, staff failed to provide timely help, impacting their dignity and quality of life. Interviews revealed staff did not adhere to facility policies for regular checks and personal hygiene assistance.
A resident with dementia and moderate cognitive impairment fell and sustained a head laceration after being left unattended by a nursing assistant during ambulation. The resident, who required supervision and assistance according to their care plan, reported feeling weak and dizzy. The nursing assistant left the resident to retrieve a wheelchair, resulting in the fall. The incident was captured on video, and staff interviews confirmed the failure to adhere to the resident's care plan, which required continuous assistance.
The facility failed to properly label and date food items, maintain a clean kitchen, and ensure proper hand hygiene and glove use by staff, leading to potential risks for all 65 residents.
The facility failed to submit accurate staffing data for Quarter 1, 2023, to CMS. Discrepancies were found between staff schedules and timecards, leading to inaccuracies in the PBJ report. The DHR confirmed the inaccuracies during interviews.
The facility failed to ensure safe water temperatures in five resident bathrooms and an eye wash station, with temperatures ranging from 121 to 131 degrees Fahrenheit. The maintenance director admitted to not checking the water temperatures, and a resident reported warm water during personal care. The facility's Water Management Program indicated that water temperatures should be kept below 120 degrees Fahrenheit.
The facility failed to ensure proper donning and doffing of PPE for a resident with a urinary catheter and did not implement EBP for 14 other residents with various medical conditions. Additionally, staff did not follow proper hand hygiene and laundry transportation protocols, leading to potential contamination risks. The infection prevention nurse and director of nursing confirmed that EBP had not been implemented per CDC recommendations.
A resident with quadriplegia and traumatic brain injury was observed with a soiled shirt throughout the day, despite expressing discomfort. Nursing staff acknowledged the issue but did not change the shirt promptly, affecting the resident's dignity and comfort. Facility policy emphasized immediate action to maintain dignity, which was not followed.
A resident reported and observations confirmed that her room was filthy, with a soiled privacy curtain and unclean floor. Housekeeping staff acknowledged that the curtain should have been replaced and the floor cleaned more thoroughly, including under the bed. The facility's cleaning policies and procedures were not followed, leading to the deficiency.
The facility failed to change soiled clothing for a resident with quadriplegia and traumatic brain injury, and did not assist another resident with severe cognitive impairment in shaving, despite both being dependent on staff for these activities.
A facility failed to ensure timely assistance with repositioning and did not implement care planned interventions for a resident with pressure ulcers. The resident was not wearing heel protectors, the air mattress was off, and the resident was not repositioned for over three hours. Staff were unaware of the care plan requirements, and the facility's policy on turning and repositioning was not followed.
A facility failed to provide necessary hand splinting and ROM services for a resident with cognitive impairment and hemiplegia, leading to a decline in the resident's ROM. Despite a detailed care plan, staff frequently did not apply the required splints or perform ROM exercises, and documentation showed many instances of non-compliance. Interviews revealed a lack of communication, training, and accountability among staff regarding the resident's restorative program.
The facility failed to ensure that two residents were offered or received pneumococcal and/or influenza vaccinations as per CDC recommendations. Despite having policies in place, the facility lacked a process to ensure immunizations were completed, as confirmed by the infection preventionist and the director of nursing.
The facility failed to maintain safe storage of medications when two out of three medication carts were left unlocked and unattended. LPNs were observed accessing the carts without using keys, despite acknowledging the importance of locking them. The DON confirmed that medication carts should be locked when not in direct attendance, as per facility policy.
The facility failed to maintain proper infection control practices during blood glucose checks for two residents. An LPN placed contaminated lancets in a plastic cup on the medication cart and did not disinfect the glucometer. Another LPN checked a resident's blood glucose without wearing gloves. Staff interviews and document reviews confirmed these deficiencies.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for all residents reviewed, with specific concerns raised by six residents. The issues were documented through grievances and resident council meeting minutes, which highlighted ongoing complaints about cold meals. Observations and interviews with residents and family members revealed that meals were often served cold, with some food items being undercooked or overcooked, making them difficult to eat. Residents expressed frustration with the temperature and quality of the food, and some resorted to bringing in outside food or making their own meals. During observations, it was noted that food was left on meal carts in hallways for extended periods before being served, contributing to the temperature issues. Staff interviews revealed that food temperatures were not consistently checked during serving, and there were issues with the steam table not maintaining adequate temperatures. The kitchen manager acknowledged problems with the steam table and the lack of proper temperature monitoring, which led to food being served at unsafe temperatures. The facility's food temperature logs showed discrepancies in recorded temperatures, and staff were using incorrect forms for documentation. The facility's policy required hot foods to be maintained at 150 degrees Fahrenheit or above, but observations showed that many food items were served below this temperature. The kitchen manager admitted that some foods were not safe to serve due to low temperatures and that corrective actions were not consistently taken. The facility's failure to maintain safe food temperatures and address resident complaints resulted in a deficiency that had the potential to affect all residents in the facility.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to ensure dignified and respectful care for two residents, R2 and R4, by not providing necessary services such as emptying bedside urinals and adhering to scheduled bathing routines. R2, who had moderate cognitive impairment and required assistance with mobility and toileting, was left with full urinals on his bedside table, which were not emptied by staff in a timely manner. This neglect led to R2 feeling embarrassed and frustrated, as he had to wait for long periods for assistance, impacting his dignity and quality of life. R4, who had intact cognition but required assistance with personal hygiene and toileting due to limited mobility, experienced similar neglect. Despite being scheduled for baths twice a week, R4 often did not receive them, leading to feelings of embarrassment and discomfort. The facility's failure to update the bath schedule and ensure staff were aware of the changes contributed to this deficiency. R4's care plan indicated a need for regular bathing to maintain hygiene and prevent skin issues, but this was not consistently provided. Interviews with staff revealed a lack of adherence to facility policies regarding resident care and dignity. Staff were expected to perform regular checks and assist with personal hygiene needs, but these duties were not consistently fulfilled. The facility's policies emphasized the importance of treating residents with respect and dignity, yet the actions and inactions observed in the care of R2 and R4 demonstrated a failure to uphold these standards, resulting in a deficiency in the quality of care provided.
Failure to Implement Ambulation Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to implement proper ambulation interventions for a resident with a history of falls, resulting in actual harm. The resident, who had diagnoses of dementia and moderate cognitive impairment, required supervision or touching assistance when ambulating, as indicated in their care plan. On the day of the incident, the resident was being assisted by a nursing assistant (NA) while ambulating in the hallway. The resident reported feeling weak and dizzy, prompting the NA to leave the resident unattended to retrieve a wheelchair, during which time the resident fell and sustained a head laceration. The incident was captured on facility video surveillance, showing the NA leaving the resident alone in the hallway, which was against the care plan that required the resident to have assistance of one staff and a front-wheeled walker. The NA acknowledged being familiar with the resident's care plan and admitted to leaving the resident unattended due to the absence of immediate help and lack of a walkie-talkie. The fall resulted in the resident requiring emergency medical care, including treatment for a 2 cm laceration on the posterior scalp with three staples and a head CT scan to rule out intracranial hemorrhage. Interviews with staff members, including a licensed practical nurse (LPN) and registered nurses (RNs), confirmed that the NA should not have left the resident unattended, especially given the resident's history of falls. The staff acknowledged that the NA should have called for help and maintained support for the resident. The facility's Activities of Daily Living (ADLs) Policy and Procedure emphasized the need for appropriate care and services to prevent a decline in residents' abilities, which was not adhered to in this case.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to ensure food items were properly labeled and dated after packaging was opened, and did not maintain a clean and sanitary kitchen area. During an initial tour of the kitchen, surveyors observed multiple instances of opened and undated food items in various freezers and refrigerators, including chicken patties, breaded steaks, garlic bread, shredded carrots, orange juice, tarter sauce, and beef base. Additionally, the kitchen had several cleanliness issues, such as spills and crumbs in the freezers, dishes stored on the floor, wet and soiled trays, and a dirty metal fan stored near food items. The registered dietician and kitchen supervisor confirmed these observations and acknowledged that the dietary manager should have been routinely inspecting the kitchen to ensure compliance with food safety standards. Further observations revealed that a cook was not following proper hand hygiene and glove use protocols while serving food. The cook was seen touching various items, including meal tickets, trays, and utensils, without changing gloves or washing hands before handling food. The dietary manager confirmed that staff were expected to use gloves for single use only and to change gloves and wash hands when switching tasks. The facility's policies on food safety and handwashing emphasized the importance of these practices to prevent foodborne illness and maintain resident health, but these protocols were not being followed, leading to potential risks for all 65 residents in the facility.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing data for Quarter 1 (October 1-December 31, 2023) to the Centers for Medicare and Medicaid Services (CMS). The Payroll-Based Journal (PBJ) report identified excessively low weekend staffing, specifically on October 14, 2023. During an interview, the administrator confirmed that the director of human resources (DHR) was responsible for submitting the PBJ. A review of staff timecard punches and facility schedules revealed discrepancies, such as a nursing assistant (NA-C) working more hours than scheduled and a licensed practical nurse (LPN-B) working without being scheduled. These discrepancies indicated inaccuracies in the PBJ report submitted to CMS. The DHR explained that the process for submitting the PBJ involved the corporate office running a spreadsheet, which was then sent to the DHR for additional data entry before being sent back to corporate. The DHR also reported that weekend staffing typically consisted of four to six nursing assistants, depending on the facility's census, and two nurses on the night shift and three on the day shift. However, the review of schedules and timecards showed inconsistencies, leading to the verification of inaccuracies in the PBJ report for two staff members on October 14, 2023.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure an environment free of accident hazards related to hot water temperatures in five resident bathrooms and the sink at the eye wash station. During a resident screening, the water temperature in a resident's bathroom felt very hot to the touch after running for only a few minutes. The maintenance director verified the water temperatures in several other resident bathrooms and found them to be excessively high, ranging from 121 to 131 degrees Fahrenheit. These temperatures were confirmed to be too hot and had the potential to cause burns. Additionally, a licensed practical nurse verified that four residents who were independent with mobility on the memory care unit had the potential to turn on these hot water sinks. The maintenance director admitted to not checking the water temperatures and was unaware they were running hot. The facility's Water Management Program indicated that water temperatures should be kept below 120 degrees Fahrenheit, and resident rooms at the end of wings, as well as common area bathrooms, should have been routinely checked and recorded. During a resident council meeting, a resident mentioned that the water in her bathroom had recently felt warm when staff were providing personal care. The administrator stated that his expectation was for water temperatures to remain within State and Federal guidelines.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to ensure proper donning and doffing of personal protective equipment (PPE) to prevent the spread of infection for one resident observed for enhanced barrier precautions (EBP). Specifically, a nursing assistant did not wear a gown while performing high-contact activities for a resident with a urinary catheter. The nursing assistant admitted to not receiving clear education on the required PPE for EBP. Additionally, the facility did not identify and implement EBP for 14 other residents who required such precautions due to various medical conditions, including surgical incisions, pressure injuries, and urinary catheters. There was no PPE located near these residents' rooms for staff to use during high-contact care activities, and no signs indicating EBP were posted outside their rooms. The facility also failed to ensure proper hand hygiene and the transportation of personal laundry in a manner that prevented contamination. During observations, a dietary aide touched the tops of drinking glasses with bare hands, and a nursing assistant delivered laundry using an uncovered cart without sanitizing hands between resident rooms. The laundry cart remained uncovered during the entire observation, and the nursing assistant admitted to not following the facility's policy on sanitizing hands and covering the cart. Similarly, a housekeeper was observed delivering laundry with a partially covered cart and did not sanitize hands during the entire process. The infection prevention nurse (IP) and the director of nursing (DON) confirmed that the facility had not implemented EBP per CDC recommendations. The IP stated that she was unaware of the CDC's recommendations for EBP and that the facility had only begun training staff on EBP that day. The DON verified that EBP had not been implemented for residents as per CDC guidelines and confirmed her expectations for staff to follow EBP and PPE recommendations to prevent the spread of infections.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure dignity was maintained for a resident (R54) who had a soiled wet shirt. R54, who was cognitively intact and had diagnoses including quadriplegia and traumatic brain injury, was observed with a wet and brown soiled area on his shirt by the neckline. Despite indicating that the soiled shirt made him feel uncomfortable, the resident remained in the same soiled shirt throughout the day, even during meal times. Nursing staff acknowledged the soiled shirt but did not change it promptly, which affected the resident's dignity and comfort. During interviews, nursing staff and the interim director of nursing confirmed that the expectation was to change a resident's soiled shirt immediately to maintain dignity. The facility's policy on resident rights and dignity emphasized treating each resident with respect and ensuring their quality of life. However, the staff failed to adhere to this policy, resulting in the resident remaining in a visibly soiled shirt for an extended period.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to ensure housekeeping services were provided for a clean environment for a resident (R115) who had a soiled privacy curtain and floor. R115, who was cognitively intact and had diagnoses including anxiety, depression, and joint replacements, reported that her room was filthy. Observations confirmed the presence of brown smears and spots on the privacy curtain, dust, crumbs, plastic medication cups, and a wadded paper towel under the bed. Additionally, a drip/spill was noted on the outside of her wardrobe closet. R115 indicated that it had been four to five days since her floor was mopped and that the area under the bed was not cleaned often. Housekeeping staff confirmed these observations and acknowledged that the curtain should have been replaced and the floor cleaned more thoroughly, including under the bed. The facility's policy and deep clean sheet procedures were not followed as expected, leading to the deficiency in maintaining a clean environment for R115. During interviews, housekeeping staff indicated that their usual practice included sweeping and mopping the room, including under the bed, and replacing soiled curtains. However, the housekeeping lead stated that floors were typically swept and mopped once or twice a week if they appeared clean, and privacy curtains were usually replaced during room turnover. The housekeeping lead was unaware if R115's privacy curtain had been changed before her arrival. R115 reported that her curtain was soiled upon her arrival and expressed concerns about the dust affecting her breathing. The facility's failure to adhere to its cleaning policies and procedures resulted in an unclean environment for R115, as confirmed by multiple observations and staff interviews.
Failure to Change Soiled Clothing and Assist with Shaving
Penalty
Summary
The facility failed to change soiled clothing for a resident (R54) who was dependent on staff for dressing, bathing, and personal hygiene. R54, who has quadriplegia and traumatic brain injury, was observed with a wet and brown soiled area on his shirt that was not changed throughout the day despite expressing discomfort. Nursing assistant (NA)-H admitted to not noticing the soiled shirt and stated that she would have changed it if she had noticed it sooner. The clinical manager confirmed that staff should change soiled clothing immediately. Additionally, the facility failed to assist another resident (R36) with shaving, despite the resident's severe cognitive impairment and dependency on staff for personal hygiene. R36 was observed with long facial hair on multiple occasions, and both the nursing assistant and licensed practical nurse admitted to not assisting with shaving. The interim director of nursing confirmed that R36 required staff assistance with shaving and expected that it should be done daily or when facial hair was present.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure timely assistance with repositioning and did not implement care planned interventions for a resident with current pressure ulcers and at risk for further development of pressure ulcers. The resident, who had diagnoses including cognitive impairment, hypertension, dementia, and anxiety, required total assistance for bed mobility and transfers. The care plan indicated the resident should have heel protectors on while in bed, be repositioned every two hours, and have a special air mattress to relieve pressure. However, observations revealed that the resident was not wearing heel protectors, the air mattress was off, and the resident was not repositioned for over three hours. Interviews with staff confirmed that they were unaware of the care plan requirements, such as the use of heel protectors and the special air mattress. The infection preventionist and the director of nursing both acknowledged that the resident had not been repositioned as required and that the care plan was not followed. The facility's policy on turning and repositioning, which mandates turning dependent residents every two hours and floating the heels off the bed, was not adhered to in this case.
Failure to Provide Hand Splinting and ROM Services
Penalty
Summary
The facility failed to provide hand splinting and range of motion (ROM) services to prevent a potential decrease in ROM for a resident who required these services. The resident had moderate cognitive impairment and diagnoses including stroke, hemiplegia, hemiparesis, and aphasia. The resident's care plan included the use of a resting hand splint in the morning and at bedtime, as well as a passive ROM program. However, documentation and observations revealed that these interventions were not consistently implemented, and the resident was often observed without the required splints or palm protector. The resident's care plan and restorative nursing program outlined specific interventions to maximize ROM and manage contractures, including the application of a blue palm protector during the day and a gray splint at night. Despite these detailed instructions, staff frequently failed to apply the splints or complete the ROM exercises. Documentation showed numerous instances where the interventions were marked as not applicable, refused, or not completed, with many entries left blank. Observations confirmed that the resident was often without the required splints, and staff interviews indicated a lack of awareness and training regarding the resident's restorative program. Interviews with staff, including nursing assistants and therapy personnel, highlighted a lack of communication and accountability in implementing the resident's restorative program. Staff were unsure who was responsible for the program and admitted to not consistently performing the required ROM exercises or applying the splints. The therapy department provided initial training and written instructions but did not offer ongoing education or oversight. The resident's primary care physician and the interim director of nursing were not informed of the resident's refusals or the failure to implement the restorative program, leading to a decline in the resident's ROM and overall condition.
Failure to Ensure Residents Received Recommended Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, aged 77 and 67, were offered or received pneumococcal and/or influenza vaccinations in accordance with CDC recommendations. The review of the immunization reports and medical records for these residents revealed that one resident had not been offered the influenza vaccine for the current seasonal flu year, and the other resident had not received the recommended pneumococcal vaccine. Interviews with the infection preventionist (IP) and the director of nursing (DON) confirmed that the facility lacked a process to ensure immunizations were completed for residents, despite having standing orders for these vaccinations. The facility's policies on seasonal influenza and pneumococcal vaccines indicated that all residents should be assessed for eligibility and offered the vaccines unless medically contraindicated or already vaccinated. The policies also required documentation of education provided to residents or their legal representatives and any refusals of vaccination. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation and confirmation that the residents in question had been offered or received the necessary vaccinations. The IP and DON both acknowledged the oversight and the absence of a systematic process to ensure compliance with vaccination protocols.
Failure to Maintain Safe Storage of Medications
Penalty
Summary
The facility failed to maintain safe storage of medications when two out of three medication carts were left unlocked and unattended. On one occasion, an LPN gathered supplies to check a resident's blood glucose and left the medication cart in the hallway, partially locked, while attending to the resident in their room. The LPN admitted that the lock was in working order and acknowledged the importance of locking the cart to prevent theft, but stated that he trusted the people and residents at the facility. Another LPN was observed accessing a medication cart without using a key, stating that she had a key but habitually did not use it to lock the cart. Both LPNs acknowledged that leaving the carts unlocked was not safe. The Director of Nursing (DON) confirmed that medication carts should be locked whenever a nurse is not in direct attendance. The facility's policy on medication storage, dated 2/12/24, directed that medications and biologicals should be stored securely and that compartments containing these items should be locked when not in use. The policy also specified that carts used to transport medications should not be left unattended. Despite this policy, the observed actions of the LPNs demonstrated a failure to adhere to these safety protocols, posing a risk that unauthorized individuals could access the medication carts.
Infection Control Deficiency During Blood Glucose Checks
Penalty
Summary
The facility failed to maintain proper infection control practices during blood glucose checks for two residents. One resident with diabetes mellitus type 2 had their blood glucose checked by an LPN who placed a contaminated lancet and cotton ball in the cover of a plastic container used to hold the resident's glucometer and other supplies. The LPN then placed the contaminated lancet in a plastic cup on the medication cart, which already contained five used lancets. The LPN did not disinfect the glucometer or the plastic container and stated that glucometers were cleaned only once weekly unless used for another resident. The sharps container on the medication cart was observed to be overfilled, with contents approximately two inches above the full line. Another LPN was observed checking the blood glucose of a second resident with diabetes mellitus type 1 and end-stage renal disease without wearing gloves. This LPN also stated that glucometers were cleaned only once weekly unless visibly dirty and that there was no specific process for the day of the week the glucometers were cleaned. Interviews with other staff members, including another LPN and the Director of Nursing (DON), revealed that gloves should be worn for all glucometer testing, and sharps containers should be replaced when the contents reach the full line. The DON confirmed that glucometers were expected to be cleaned after each use and that it was unacceptable to place contaminated lancets in a plastic cup on the medication cart. Facility documents also directed that blood glucose monitoring procedures include hand hygiene, wearing gloves, and cleaning the glucometer per facility policy after each use. The facility's failure to adhere to these infection control practices was observed and confirmed through staff interviews and document reviews.
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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 Saint Cloud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Benedicts Care Center | 0.5 mi | ★★★★★ | 2 | 0 |
| Sterling Park Health Care Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Lutheran Home | 4.4 mi | ★★★★★ | 0 | 0 |
| Country Manor Health & Rehab Ctr | 5.6 mi | ★★★★★ | 4 | 0 |
| Sartell Therapy Suites | 7.9 mi | — | 0 | 0 |
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