Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Carondelet Village Care Center during CMS and state inspections, most recent first.
Failure to keep a resident's walker within reach for a resident at risk for falls. The resident had cognitive impairment, Parkinsonism, dementia, heart failure, and a history of repeated falls with injuries, and the care plan and care sheet directed staff to keep the walker beside the resident at all times because the resident self-transferred. During observation, an LPN left the room while the resident was receiving a nebulizer treatment and the walker was folded against the wall and out of reach; an NA later confirmed the walker should have been by the resident and placed it beside the resident.
Failure to Ensure Updated Pneumococcal Vaccinations: Two residents did not have evidence of updated pneumococcal vaccination per CDC guidance. One resident had prior PPSV23 and PCV13, a consent to receive recommended vaccines, and a care conference note stating the resident was due, but the chart lacked evidence of shared clinical decision-making or PCV20/PCV21 administration. Another resident had PCV13 only, an admission order for pneumococcal vaccination if not already received, but the MAR, TAR, and immunization record lacked evidence of PCV20/PCV21 being given. The IP, RDCS, and DON acknowledged both residents were due and had missed the vaccinations.
A resident's DNR/DNI wishes were not respected due to an outdated POLST in the EMR, leading to CPR being performed against her wishes. The resident was fully cognitively intact and had a signed POLST indicating DNR/DNI, but staff initiated CPR based on an outdated full code status in the EMR. The error was discovered only after EMS requested the code status documentation.
The facility failed to store ice packs separately from food in unit kitchenette refrigerators, potentially affecting 45 residents. Ice packs were found among food items, contrary to facility policy. Additionally, a cook served food without a beard guard, violating hair restraint policies. Interviews confirmed these practices were not aligned with expected standards.
Failure to Keep Walker Within Reach for a Resident at Risk for Falls
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a history of falls. The resident had moderate cognitive impairment, Parkinsonism, non-Alzheimer's dementia, heart failure, an artificial hip joint, impaired mobility, and required extensive assistance with bed mobility, transfers, and toilet use. The resident's care plan and care sheet directed staff to provide assist with transfers and ambulation, use a gait belt and rolling walker, keep the walker within reach at all times, and place signage on the walker to remind the resident to take it when moving about because the resident self-transferred and was at risk for falls. The resident had multiple falls documented in the record, including a fall that resulted in a hip fracture, another fall while standing and washing hands, and additional falls with bruising, abrasion, laceration, forehead injury, and a skin tear. Following these incidents, the record continued to identify the walker as a required intervention and staff were educated to keep the walker beside the resident and follow the care plan. The resident's care sheet dated 11/17/25 continued to indicate the walker was to remain within reach because the resident self-transferred in the room and was at risk for falling. During observation, an LPN left the resident's room while the resident was receiving a nebulizer treatment, and the resident's walker was folded against the wall next to the television and not near the resident. The resident was later observed in the room with the walker still folded in the corner and out of reach. An NA stated the walker should be by the resident and unfolded it, and staff interviews confirmed they expected the care sheet and care plan to be followed. The DON stated staff were expected to keep the walker with the resident at all times, and the RDCS confirmed staff had been educated to follow the care plan.
Failure to Ensure Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure two residents were offered and/or provided updated pneumococcal vaccination in accordance with CDC recommendations. Review of CDC guidance showed that adults 65 years or older may receive PCV20 or PCV21 under shared clinical decision-making after prior pneumococcal vaccination history, and that adults 50 years or older who previously received PCV13 only may receive a single dose of PCV20 or PCV21 after one year. The facility’s policy stated residents were to be offered pneumococcal immunization unless contraindicated, declined, or already immunized, and that vaccination status was to be determined on admission or soon thereafter with shared clinical decision-making completed when applicable. For one resident, the record showed PPSV23 in 2005 and PCV13 in 2015, a consent form indicating the resident wanted recommended pneumococcal vaccinations, and a care conference note stating the resident was due for a pneumococcal vaccination. However, the medical record lacked evidence that shared clinical decision-making occurred or that PCV20 or PCV21 was given. For the second resident, the record showed PCV13 in 2015, an admission order to receive pneumococcal vaccinations if not already received, and a consent form stating vaccination status was up to date, but the MAR, TAR, and immunization record lacked evidence that PCV20 or PCV21 was administered at least one year after PCV13. During interviews, the IP, RDCS, and DON acknowledged both residents were due for additional pneumococcal vaccination and that the residents had missed them.
Failure to Honor Resident's DNR/DNI Wishes
Penalty
Summary
The facility failed to respect the resuscitation wishes of a resident, resulting in the administration of CPR against her established wishes. The resident, who was fully cognitively intact, had a POLST indicating Do Not Attempt Resuscitation (DNR) and Do Not Intubate (DNI), which was signed and uploaded to her electronic medical record (EMR). However, an outdated POLST indicating full code status was not corrected in the EMR, leading to the administration of CPR when the resident was found unresponsive. The incident occurred when the resident was found unresponsive in her room, and staff initiated CPR based on the outdated full code status displayed in the EMR. The nursing staff, unaware of the updated POLST, performed CPR until emergency medical services (EMS) arrived and continued the resuscitation efforts. It was only after EMS requested the code status documentation that the signed POLST indicating DNR/DNI was discovered, and CPR was subsequently stopped. Interviews with the nursing staff revealed a gap in communication and process for updating code statuses in the EMR. The facility's previous process involved obtaining a new POLST from the resident and placing it in the provider's box for review, which led to delays in updating the EMR. The staff involved were unaware of the resident's updated wishes due to this communication breakdown, resulting in the failure to honor the resident's end-of-life preferences.
Improper Storage of Ice Packs and Hair Restraint Use
Penalty
Summary
The facility failed to ensure proper storage of ice packs separate from food items in the unit kitchenette refrigerators, which had the potential to affect all 45 residents receiving food from these areas. Observations revealed that ice packs, some labeled with resident names and others unlabeled, were stored among frozen food items such as boxed meals, ice cream, and yogurt in the freezers of three different neighborhood kitchenettes. Interviews with nursing assistants and the care center food service supervisor indicated that the ice packs were intended for resident use and were sanitized and returned to the freezer after use. However, the culinary director was unaware of this practice and confirmed that ice packs should not be stored with food due to sanitary reasons. The facility's policy stated that reusable ice packs should be disinfected and stored in a dedicated freezer area, separate from food. Additionally, the facility failed to ensure the proper use of hair restraints during food service. An observation in the care center's main dining area showed a cook with a full beard serving food without wearing a facial hair/beard guard. The food service supervisor confirmed that beard guards were available and should have been worn by the cook while serving food. The culinary director restocked the hair restraint supply and stated that the expected practice was for staff to wear hair nets, including beard guards, while plating food. The facility's policy required beards to be covered with a beard bag before entering areas where food is prepared.
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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 Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hayes Residence | 0.5 mi | ★★★★★ | 0 | 0 |
| Highland Chateau Health And Rehabilitation Center | 1.6 mi | — | 55 | 2 |
| Mn Veterans Home Minneapolis | 1.6 mi | ★★★★★ | 1 | 1 |
| Shirley Chapman Sholom Home East | 2 mi | ★★★★★ | 0 | 0 |
| Episcopal Church Home Of Minnesota | 2 mi | ★★★★★ | 17 | 1 |
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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.