Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Catholic Eldercare On Main during CMS and state inspections, most recent first.
A facility failed to reassess and implement necessary interventions for a resident with severe cognitive impairment who experienced two choking episodes while eating unsupervised. The care plan was not updated, and there was no comprehensive reassessment after the second incident. Additionally, the facility did not conduct a comprehensive fall risk assessment for another resident with severe cognitive impairment, resulting in multiple falls and injuries. The facility's inaction led to immediate jeopardy and actual harm.
The facility failed to cover residents' clothing during storage and delivery, potentially affecting all residents. Laundry aides and the director of environmental services confirmed that personal laundry carts were never covered, contrary to the facility's policy. The DON acknowledged that covering the carts is necessary to minimize cross-contamination.
The facility failed to provide a dignified, home-like dining environment, as residents were served meals on hard plastic trays with plates on warmers, and drinks and silverware placed on the trays. Observations across multiple dining rooms showed this setup was consistent, and interviews revealed no rationale for this method. A resident expressed a preference for a more home-like experience, while staff indicated a lack of policy guidance on promoting such an environment.
The facility failed to provide appropriate wheelchair foot supports for a resident, leading to unsupported feet while seated. Another resident did not consistently receive ordered skin protectors, increasing the risk of skin tears or bruising. Additionally, a resident undergoing dialysis missed multiple insulin doses due to an unadjusted administration schedule, resulting in elevated blood glucose levels. Staff failed to communicate these issues to the provider in a timely manner.
A resident with chronic pain and other health issues did not receive consistent pain assessments or non-pharmacological interventions before being given as-needed narcotic medication. The facility failed to document pain levels and locations adequately, and non-pharmacological options were not offered or recorded, leading to insufficient pain management.
A facility failed to monitor target behaviors for a resident prescribed antipsychotic medication, quetiapine, for delusional disorder. The resident's care plan and MAR/TAR initially lacked documentation of target behaviors, which were only added later. Observations showed the resident was calm and engaged in activities, with no signs of agitation or paranoia. Staff confirmed the importance of monitoring target behaviors to assess medication effectiveness, which was not done until after the deficiency was identified.
A resident with Parkinson's disease did not receive timely follow-up dental care as recommended, due to the facility's lack of coordination and tracking of dental appointments. Despite a recommendation for a follow-up visit 3 months after a dental appointment, the resident had not been seen for 5 or 6 months. Interviews with staff revealed a lack of clarity and responsibility in scheduling and tracking dental appointments, and no policy on dental appointments was provided.
Deficiencies in Resident Safety and Risk Management
Penalty
Summary
The facility failed to adequately reassess and implement necessary interventions for a resident (R67) who experienced two choking episodes while eating unsupervised. Despite having severe cognitive impairment and a history of choking, the resident continued to eat unsupervised in their room. The facility did not update the care plan or conduct a comprehensive reassessment after the second choking incident, which required staff intervention. The care plan lacked specific instructions on supervision frequency, and there was no documented discussion of the risks and benefits of the resident's diet with the resident or their responsible party. Additionally, the facility did not conduct a comprehensive fall risk assessment for another resident (R107) upon admission or after multiple falls. The resident, who had severe cognitive impairment and a history of falls, sustained a head laceration and a fractured hip from falls. The facility's documentation lacked evidence of a root-cause analysis or consideration of proactive interventions to prevent further falls. The care plan was not updated with effective interventions despite the resident's repeated falls and injuries. The facility's inaction in both cases resulted in immediate jeopardy for R67 and actual harm for R107. The lack of timely reassessment and intervention updates in response to these incidents highlights deficiencies in the facility's approach to managing accident hazards and ensuring resident safety.
Uncovered Laundry Carts Lead to Potential Contamination
Penalty
Summary
The facility failed to ensure that residents' clothing was covered during storage and delivery, which had the potential to affect all residents. During observations and interviews, it was noted that laundry aides were pushing large, uncovered laundry carts containing cleaned resident clothing items down the hallways on both the first and second floors. The laundry aides confirmed that they had never covered the personal laundry carts. The director of environmental services-housekeeping and laundry also stated that the carts used to deliver personal clothing had never been covered, as it was the facility's process to only cover carts used for bed linen and towels. The director of nursing acknowledged that personal clothing carts should be covered to minimize possible cross-contamination. The facility's policy on laundering linen and resident clothing, revised in 2016, indicated that all linen and resident clothing should be cleaned and handled in a manner that prevents contamination and decreases the risk of spreading infection. The policy also specified that clean linen and clothing should be sorted and folded in the laundry and placed on covered shelves or racks for transport to nursing stations.
Failure to Provide a Home-like Dining Environment
Penalty
Summary
The facility failed to promote a dignified, home-like environment during dining services in four out of six dining rooms reviewed. Observations revealed that residents were served meals on hard plastic trays with their plates sitting on plate warmers. Drinks and silverware were also placed on these trays, and hard plastic dome-shaped lids, which were used to cover the food plates, were left in the middle of the tables. This setup was consistent across multiple dining rooms and observed on several occasions. Interviews with residents and staff highlighted a lack of rationale for serving meals in this manner. One resident expressed a desire for a more home-like dining experience and noted that the current method might be easier for staff but was not her preference. A registered nurse and the facility administrator both indicated that there was no specific reason for using the plastic trays, and the director of nursing deferred the question to dietary staff, declining to comment further. The facility's policy on serving meals and feeding residents, last revised in 2016, did not provide guidance on promoting a dignified home-like environment during dining services. This lack of policy direction contributed to the deficiency, as the facility did not have a structured approach to ensure that dining services were conducted in a manner that respected residents' rights to a comfortable and homelike environment.
Deficiencies in Wheelchair Support, Skin Protection, and Insulin Management
Penalty
Summary
The facility failed to ensure appropriate wheelchair foot supports for a resident with severe cognitive impairment, leading to the resident's feet dangling unsupported while seated in a wheelchair. Despite the resident's care plan indicating the use of a Broda wheelchair and the need for total assistance, there was no rationale or instruction regarding the lack of wheelchair pedals or platform. Observations over two days showed the resident without foot supports, and staff interviews revealed a lack of awareness and communication about the necessity of foot pedals, with no recent therapy consultation for wheelchair positioning. Another deficiency involved the facility's failure to consistently implement proactive skin interventions for a resident at risk of skin tears or bruising. The resident, who had severe cognitive impairment, was observed multiple times without the ordered skin protectors, despite a physician's order for bilateral protectors to be worn at all times. Interviews with staff and family indicated inconsistency in the use of protectors, and the resident's care plan lacked guidance on this intervention. The Treatment Administration Record showed the order was signed off as completed, despite observations to the contrary. The facility also failed to assess and revise an insulin administration schedule for a resident undergoing dialysis, resulting in missed doses of insulin. The resident, who had end-stage renal disease and type 2 diabetes, missed her noon insulin dose on multiple occasions due to dialysis appointments. Despite the resident's concerns about her blood glucose management, staff did not notify the provider of the missed doses or adjust the insulin schedule until after the surveyor's inquiry. The resident's blood glucose levels were frequently above 200, and the facility's failure to address the missed doses was not communicated to the provider in a timely manner.
Inadequate Pain Management and Documentation for a Resident
Penalty
Summary
The facility failed to consistently assess a resident's pain level before administering as-needed narcotic pain medication and did not implement non-pharmacological pain interventions for a resident identified as R106. R106, who had intact cognition and various diagnoses including polyneuropathy, muscle weakness, and chronic pain, reported frequent pain that occasionally affected sleep. Despite having a care plan that included both pharmacological and non-pharmacological interventions, the facility did not adequately document or offer these interventions. R106's Medication Administration Record (MAR) showed that oxycodone was administered multiple times without proper documentation of pain assessment, including pain scale and location. Out of 26 administrations of oxycodone, only 5 had a pain scale documented, and only 2 had the location of pain noted. Additionally, there was no documentation of the use or refusal of other prescribed medications like acetaminophen, tizanidine, or non-pharmacological interventions such as aromatherapy and Healing Touch. Interviews with facility staff, including registered nurses and the director of nursing, confirmed that the expected procedures for pain assessment and documentation were not followed. The facility's policy required non-pharmacological interventions to be offered and documented before administering PRN pain medication, which was not done for R106. The lack of proper documentation and assessment led to inadequate pain management for the resident.
Failure to Monitor Target Behaviors for Antipsychotic Medication
Penalty
Summary
The facility failed to monitor resident-specific target behaviors related to the use of antipsychotic medications for one resident, identified as R105, who was reviewed for unnecessary medications. R105's quarterly Minimum Data Set indicated moderately impaired cognition without hallucinations, delusions, or behavioral symptoms, yet the resident received antipsychotic medication, quetiapine, for delusional disorder. The Physician Order Report lacked documentation of target behaviors or directions for monitoring them. Additionally, R105's care plan and Medication Administration Record (MAR/TAR) did not initially include target behavior monitoring, which was only added on a later date. Observations of R105 over several days showed the resident was calm, pleasant, and engaged in activities like sewing, with no signs of agitation, aggression, or paranoia. Interviews with facility staff, including a nurse practitioner, pharmacist consultant, registered nurse, and director of nursing, confirmed the importance of monitoring target behaviors to assess the effectiveness and necessity of antipsychotic medications. The facility's policy on psychotropic medication required the addition of target behaviors to the care plan and the initiation of a monitoring graph, which was not followed in R105's case until after the deficiency was identified.
Failure to Coordinate Dental Care for Resident
Penalty
Summary
The facility failed to ensure that dental needs were coordinated with a dental provider for a resident, identified as R88, who was reviewed for dental care and services. R88, who has Parkinson's disease and requires assistance with oral care, had not been seen by the in-house dental provider for 5 or 6 months despite a recommendation for a follow-up visit in 3 months after her last appointment on 4/19/24. During this appointment, R88 had a cavity filled and was advised to return for a follow-up. However, there was no documentation or coordination for this follow-up appointment, and R88 expressed uncertainty about when her next appointment would be. Interviews with facility staff revealed a lack of clarity and responsibility regarding the scheduling and tracking of dental appointments. The Health Unit Coordinator (HUC) was responsible for setting up initial dental appointments and urgent visits but did not track routine or follow-up appointments for residents seen by the in-house dental provider. The Registered Nurse (RN) and Director of Nursing (DON) confirmed that after-visit summaries were reviewed, but there was no system in place to ensure follow-up appointments were scheduled as recommended. The deficiency was further highlighted by the absence of a policy on dental appointments and the lack of documentation to support the coordination of dental care for R88. Despite the facility's process of reviewing after-visit summaries, there was no effective tracking system to ensure residents received timely follow-up care, leading to R88 being overdue for her dental appointment. The facility's failure to coordinate dental care and maintain adequate documentation resulted in a deficiency in providing necessary dental services to R88.
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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 Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Andrew Residence | 2 mi | — | 15 | 1 |
| Benedictine Health Center Of Minneapolis | 2 mi | — | 8 | 0 |
| Villas At Bryn Mawr Llc | 2.4 mi | — | 5 | 3 |
| The Estates At Chateau Llc | 2.4 mi | — | 13 | 1 |
| Fairview University Trans Serv | 2.5 mi | — | 0 | 0 |
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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 August 2026) and official state health department websites.