Cycle 1
Health 2025-11-20 · Fire 2025-11-20
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Saint Paul, MN
Carondelet Village Care Center
4-star overall rating with 3-star inspections with $28,538 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
525 Fairview Avenue South, Saint Paul, MN
(651) 695-5000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
2012-08-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 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
1.06
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.92
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,247
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9936
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.94
Baseline 50.00% · Performance 55.74% · Measure score 1.94 · Achievement 1.94 · Improvement 0
Adjusted total nurse staffing
6.20
Baseline 4.83 hours · Performance 4.84 hours · Measure score 6.20 · Achievement 6.20 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 0% · Lower 95% interval 5.87% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.83% |
8.2%
4.4 pts worse
|
Numerator 9 · Denominator 235 |
| Staff flu vaccination coverage | 5.51% |
42%
36.5 pts worse
|
Numerator 13 · Denominator 236 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.3%
1.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.6% · Q4 97.6% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
96.1%
1.4 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.9%
0.8 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 4.8% · Q4 4.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
4.3%
7.1 pts worse
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.6% · Q3 12.5% · Q4 16.2% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
4.1%
3.1 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.5% |
12.4%
4.9 pts better
|
19.6%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.1% · Q3 3.8% · Q4 11.5% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
17.5%
5.4 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 9.1% · Q3 8.7% · Q4 9.5% · 4Q avg 12.1% · 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 | 46.8% |
22.5%
24.3 pts worse
|
16.3%
30.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
18.6%
3.8 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 28.6% · Q3 11.5% · Q4 23.1% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.6%
1.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
24.8%
5 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 22.1% · Q3 32.6% · Q4 38.1% · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
5.4%
5 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.5% · Q3 13.0% · Q4 7.5% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
88.6%
4.7 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 94.3% · Q3 100.0% · 4Q avg 93.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
82.7%
11.4 pts better
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-17 · Fire 2024-10-17
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-11-16 · Fire 2023-11-16
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-11-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-11-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-11-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-02
F · Potential for more than minimal harm
2024-10-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-10-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-17
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-01-02
F · Potential for more than minimal harm
2023-11-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-11-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-11-16
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-11-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-11-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-11-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-11-16
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-11-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-11-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-11-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-11-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-11-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-29
C · Minimal harm
2023-11-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-11-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-01-13
J · Immediate jeopardy
2025-02-11
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-02-07
F · Potential for more than minimal harm
2024-10-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-04
D · Potential for more than minimal harm
2023-11-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-16
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-29
J · Immediate jeopardy
2023-04-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-02
Penalties and ownership
What sits behind the stars
$14,020
2025-02-11
Fine
Fine · fine $14,020
Fine
$14,518
2023-04-07
Fine
Fine · fine $14,518
Fine
Ownership
Carondelet Village Inc
5% Or Greater Direct Ownership Interest · Organization
Belanger, Margaret
Operational/Managerial Control · Individual
Belanger, Margaret
Corporate Director · Individual
Larson, Duane
Corporate Director · Individual
Meyer, Mark
Corporate Director · Individual
Meyer, Mark
Corporate Officer · Individual
Phs Management, LLC
Operational/Managerial Control · Organization
Reetz, James
Corporate Director · Individual
Reetz, James
Corporate Officer · Individual
Salguero-Mullenbach, Amber
W-2 Managing Employee · Individual
Wells Fargo Bank, National Association
5% Or Greater Security Interest · Organization
Wells Fargo Bank, National Association
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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2-star overall rating with 2-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Highland Chateau Health And Rehabilitation Center
Saint Paul, MN
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $65,361 in total fines with 42 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
MN Veterans Home Minneapolis
Minneapolis, MN
1-star overall rating with 2-star inspections with $8,190 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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