Ebenezer Integrated Care & Rehab
Ebenezer Integrated Care & Rehab in SAINT PAUL, MN — inspection on April 1, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During observation on 3/31/26 at 8:28 a.m., licensed practical nurse (LPN)-B entered R28's room to administer morning medications.
R28 was sitting up in bed with his bedside table over the bed and a breakfast tray on the table. R28's breakfast included scrambled eggs, blueberry muffin, cereal, milk and juice. R28 had eaten approximately ninety percent of the scrambled eggs and had taken some of each of the beverages.
LPN-B told R28 to go ahead and finish his eggs and then she handed him a cup containing his oral medications, which he took and swallowed. LPN-B then prepped the BG meter and pricked R28's finger and obtained a sample of blood to test for the level of blood sugar in his blood. R28's BG was
- LPN-B reviewed R28's orders and stated he needed 1 unit of insulin as indicated by the ordered
sliding scale and proceeded to inject the insulin.
During interview on 3/31/26 at 8:45 a.m., R28 stated his BG should be checked prior to eating meals since the amount of one of the insulins he received was based on the BG result and a sliding scale.
During interview on 3/31/26 at 8:49 p.m., LPN-B stated R28's BG should have been tested by 7:30 a.m., to ensure it was before breakfast. LPN-B stated testing prior to a meal would have provided a more accurate fasting BG.
During interview on 4/1/26 at 7:14 a.m., registered nurse (RN)-C stated insulin administered per sliding scale should be based on a fasting BG (before a meal) in order to ensure an accurate amount of insulin was provided.
During interview on 4/1/26 at 10:42 a.m., RN-A stated staff were expected to be checking BG before meals to get an accurate fasting BG result. RN-A stated a BG taken after a resident already started eating or completed a meal, could provide an inaccurate level and the amount of insulin provided based on the result and per sliding scale could be incorrect.
During interview on 4/1/26 at 1:21 p.m., director of nursing (DON) stated expectation for fasting BG to be taken prior to a meal and that a BG taken during or after a meal could potentially indicate a wrong dose of insulin administered per sliding scale.
Facility policy Blood Sugar Monitoring dated 4/25, instructed staff to monitor resident BG levels per provider order.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245587 04/01/2026
Ebenezer Integrated Care & Rehab 45 West 10th Street Saint Paul, MN 55102
stated R46's vascular dementia was challenging because he could not process the dangers of
implemented as written for safety.
Following a fall, the interdisciplinary team (IDT) would review any
the IDT would follow up with the staff working during the fall.During a follow up interview on 4/1/26 at 2:58 p.m., The DON stated keeping R46's feet off the footrests unless propelling was still an active intervention that should have been implemented.The facility's Fall Risk, Post Fall Investigation, Follow Up, and Care policy dated 1/26, identified Universal fall precautions are used for all patients based on individual patient needs.
Interventions should be selected based on individual patient needs.
Document interventions in the medical record.
Falls risk and interventions should be noted on the plan of care.
245587 04/01/2026
Ebenezer Integrated Care & Rehab 45 West 10th Street Saint Paul, MN 55102
During interview on 3/30/26 at 12:43 p.m., R1 stated had not seen a dentist in at least a year and a half and had not been offered to see a dentist since admission.
During interview on 3/31/26 at 12:35 p.m., registered nurse (RN)-B stated the MDS nurse would schedule the quarterly oral assessment, and the assigned nurse or charge nurse would complete the assessment as identified on the treatment administration record (TAR). If it was identified that the resident needed a dental referral due to oral issues or lack of routine dental evaluation, they would notify the provider to have a dental referral placed. RN-B further stated if the resident had a dental appointment while a resident, there would be documentation in the electronic medical record (EMR) indicating a summary of the appointment. RN-B stated if documentation could not be located, she would consult the health unit coordinator (HUC) who could determine if a referral had been made and/or an appointment scheduled or completed. RN-B stated regardless of a resident's dental status, if a resident had not seen a dentist in over two years and they did not decline an appointment; a referral should be made.
During interview on 4/1/26 at 9:49 a.m., family member (FM)-B stated could not remember the last time R28 had seen a dentist and could not recall any discussion with the facility regarding offering dental services. FM-B further stated would expect R28 to be offered routine dental care and neither she nor R28 would decline those services.
During interview on 4/1/26 at 10:13 p.m., HUC stated if a resident wanted to see a dentist, and did not have their own dental clinic, she would arrange for an appointment and transportation when she received a referral from their provider. HUC looked in R28's EMR and confirmed R28 did not have a dental appointment scheduled and had not seen a dentist since his admission.
During interview on 4/1/26 at 10:42 a.m., RN-A stated if a resident was assessed and found to need or desire to see a dentist, the nurse would request a referral from the provider, and the facility would get a consent and make the arrangements. RN-A further stated R18 should have been offered a dental referral regardless of his dental status and that routine dental care could prevent oral issues in the future.
During interview on 4/1/26 at 1:21 p.m., director of nursing (DON) stated dental referral should be recommended and arranged per resident preference. DON expected staff to address R28's lack of dental visits and offer to arrange a dental appointment.
Facility policy Consultant Visit Policy - Audiology, Optometry, Podiatry, and Dental Services dated 6/25, identified the facility was responsible for scheduling and coordinating dental consultations for residents.
The policy further indicated, Within 90 days of admission, staff will refer the resident for an initial dental examination, unless the resident has had a dental exam within six months before admission.
After the initial exam, staff will offer an annual dental exam within one year of the previous exam.