Cycle 1
Health 2025-12-18 · Fire 2025-12-18
12 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Minneapolis, MN
Catholic Eldercare On Main
4-star overall rating with 2-star inspections with $47,130 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
817 Main Street Northeast, Minneapolis, MN
(612) 379-1370
Overall
4 / 5
CMS overall stars
Health inspections
2 / 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
164
Certified beds
Average residents
152
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.28
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.39
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,778
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0089
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.65
Baseline 16.66% · Performance 20.20% · Measure score 2.65 · Achievement 2.65 · Improvement 0
Healthcare-associated infections
3.12
Baseline 4.53% · Performance 6.90% · Measure score 3.12 · Achievement 3.12 · Improvement 0
Total nurse turnover
10
Baseline 25.83% · Performance 22.16% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
5.85
Baseline 4.30 hours · Performance 4.74 hours · Measure score 5.85 · Achievement 5.85 · Improvement 2.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 11.43% · Lower 95% interval 8.54% |
| Discharge to community | 63.7% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 140 · Observed rate 60.71% · Lower 95% interval 53.84% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 92.42% |
95.27%
2.8 pts worse
|
Numerator 61 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 32 · Denominator 56 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 35 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 66 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 5.56% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 14.56% |
8.2%
6.4 pts better
|
Numerator 46 · Denominator 316 |
| Staff flu vaccination coverage | 63.58% |
42%
21.6 pts better
|
Numerator 206 · Denominator 324 |
| Discharge function score | 60.71% |
56.45%
4.3 pts better
|
Numerator 34 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.04% |
96.28%
1.8 pts better
|
Numerator 50 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 58.14% |
25.2%
32.9 pts better
|
Numerator 25 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
97.3%
5.4 pts worse
|
93.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 91.4% · Q3 90.2% · Q4 92.4% · 4Q avg 91.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
96.1%
0.1 pts worse
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.9%
1 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.9% · Q3 1.5% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.3% |
4.3%
3 pts worse
|
11.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.3% · Q3 2.8% · Q4 4.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.1%
3 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.5% · Q3 8.3% · Q4 3.8% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
12.4%
3.5 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 8.2% · Q3 7.3% · Q4 9.6% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.4% |
17.5%
3.9 pts worse
|
16.7%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 22.3% · Q3 17.8% · Q4 23.6% · 4Q avg 21.4% · 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 | 19.9% |
22.5%
2.6 pts better
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 23.2% · Q3 8.5% · Q4 20.1% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
18.6%
1.2 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 19.4% · Q3 21.3% · Q4 22.8% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
2.3%
1 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.0% · Q3 2.6% · Q4 2.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.6%
0.2 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 2.3% · Q4 3.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
24.8%
0.2 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 23.6% · Q3 24.1% · Q4 26.4% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.4%
2.8 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.9% · Q3 3.2% · Q4 1.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.3% |
88.6%
4.3 pts worse
|
81.7%
2.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 87.2% · Q3 87.5% · Q4 81.4% · 4Q avg 84.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
14.0%
8.6 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.9%
1.1 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.1% · Q4 1.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.4% |
82.7%
6.3 pts worse
|
79.7%
3.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
23.1%
0.4 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 18.8% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-18 · Fire 2024-10-18
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-11-16 · Fire 2023-11-16
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-02
F · Potential for more than minimal harm
2025-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-02
E · Potential for more than minimal harm
2025-12-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2026-02-02
E · Potential for more than minimal harm
2025-12-18
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2026-02-02
F · Potential for more than minimal harm
2024-10-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-07
C · Minimal harm
2024-10-18
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-07
F · Potential for more than minimal harm
2023-11-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-10
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 2024-01-10
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 2024-01-10
E · Potential for more than minimal harm
2023-11-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-10
D · 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 2024-01-10
C · Minimal harm
2023-11-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-10
C · Minimal harm
2023-11-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-01-10
C · Minimal harm
2023-11-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-10
C · Minimal harm
2023-11-16
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-01-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-02-02
E · Potential for more than minimal harm
2025-12-18
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 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
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 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2026-02-02
J · Immediate jeopardy
2024-10-18
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 2024-11-07
F · Potential for more than minimal harm
2024-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-18
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-02-23
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
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 2024-04-08
E · Potential for more than minimal harm
2023-11-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-28
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-25
Penalties and ownership
What sits behind the stars
$37,380
2024-10-18
Fine
Fine · fine $37,380
Fine
$9,750
2023-03-28
Fine
Fine · fine $9,750
Fine
Ownership
Bauer, John
Corporate Director · Individual
Fitzmorris, Chris
Corporate Director · Individual
Glodek, Mark
Corporate Director · Individual
Hanten, Robert
Corporate Director · Individual
Hofstede, Albert
Corporate Director · Individual
Peters, James
Corporate Director · Individual
Schrempp, Jeff
Corporate Director · Individual
Vlaminck, Lores
Corporate Director · Individual
Zeman, Patrick
Corporate Officer · Individual
Zeman, Patrick
W-2 Managing Employee · Individual
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