Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Benedictine Care Community during CMS and state inspections, most recent first.
Insufficient nursing staffing led to delayed toileting help, delayed meal assistance, and transfers done outside assessed needs and policy. A resident who was dependent for toileting and transfers was left in bed crying, incontinent, and told to stay in bed and pee her pants until staff could return, while another resident waited 45 minutes for help eating in the dining room. Surveyors also found repeated weekend staffing shortages, and staff described frequent short staffing, late or missing staff, and reliance on agency and float staff.
The facility failed to maintain an infection prevention and control program when staff did not consistently start or follow contact precautions for residents with ongoing diarrhea, including a resident later confirmed with C. diff and norovirus. The surveillance system also did not consistently track residents with signs of infection, and staff were observed providing care without proper hand hygiene or consistent PPE use. Enhanced barrier precautions were also not implemented for residents who met criteria.
The facility failed to include EBP instructions in the care plans of residents with a G-tube, a chronic wound, and an indwelling catheter. Observations showed PPE carts and signs directing staff to use gowns and gloves for direct care, but one care plan did not address EBP for G-tube or personal care, another lacked EBP guidance for wound care, and a third lacked EBP guidance for catheter care. The DON stated EBP should be care planned when required and staff were expected to follow the care plan and PPE guidance.
A resident who was dependent on staff for toileting and transfers, and who was frequently incontinent, was left in bed in only a sweatshirt and brief while crying after staff told her to stay in bed and pee her pants so they could clean her up later. The resident said this happened often and that her call light was frequently turned off. Staff interviews confirmed she should not have been told to remain incontinent, and the DON stated residents should never be told to be incontinent because it is a dignity issue.
A resident grievance about a missing hearing aid was not fully investigated, documented, resolved, or communicated to the resident’s family member. The facility only documented an initial search of the room, bedding, and laundry, with no further follow-up in the resident’s chart. The SSD said the grievance had been assigned to someone else and no outcome was shared, while the family member reported receiving no updates. The DON confirmed there was no documented follow-up and that grievances were expected to be resolved within five days.
A resident with dementia, depression, diabetes, and CHF was receiving hospice care and had an open-ended PRN order for Haldol for agitation/restlessness. The record showed no documented face-to-face provider evaluation or justification for continued use after the consultant pharmacist twice recommended discontinuation under the 14-day PRN antipsychotic limit. Staff also noted the medication made the resident sleepy, and the MAR showed it was administered during the review period.
A resident who was dependent on staff for toileting and transfers was left in bed in an incontinent brief for an extended period after asking for help, crying that staff told her to pee her pants and that this happened often. Staff later provided incontinent care and used a mechanical lift for transfer. Another resident who needed supervision and assistance with meals sat with food in front of her for 45 minutes before staff helped her eat, while staff reported the dining room was short-staffed and the resident needed more meal assistance.
Failure to perform hand hygiene between glove changes during wound care. An LPN changed dressings on a resident with multiple pressure injuries, including a heavily draining, odorous buttock wound, an unstageable coccyx ulcer, and a left heel injury, but repeatedly removed dirty gloves and put on new gloves without cleaning hands in between. The LPN said she only washed her hands before starting and after finishing, while the DON stated hand hygiene was required each time gloves were changed during wound care.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Medication Error Not Investigated or Documented: The facility failed to investigate, document, and address a reported Zepbound medication error for a resident with moderate cognitive impairment and multiple diagnoses. The event report noted a wrong dose, but the record contained no clear explanation of what occurred, no documented root cause investigation, and no documented actions taken; the DON and RN both stated the process was incomplete, and the consultant pharmacist noted the expected documentation and follow-up for medication errors.
A resident with dementia, depression, and hospice status had an open-ended PRN Haldol order for agitation and restlessness that was administered despite repeated CP recommendations to discontinue it. The record lacked the required face-to-face provider evaluation to justify continued use, and the DON stated she believed hospice status changed the 14-day PRN psychotropic review requirement.
A resident with intact cognition and no baseline hallucinations developed new hallucinations, emotional distress, vomiting, shaking, diarrhea, generalized pain, fatigue, and persistent fevers with tachycardia over several days. Despite documented vital sign abnormalities and atypical behaviors, nursing staff relied on scheduled acetaminophen, did not complete a thorough assessment, and did not notify the provider as required by facility policy. IDT discussions occurred but did not include review of progress notes or vital signs, and some staff attributed symptoms to influenza or the resident’s psychiatric history, delaying escalation. The resident was only sent to the ED after appearing pale and toxic with ongoing pain and shivering, where she was diagnosed with UTI, obstructing ureteral stone, sepsis with acute renal failure, and septic shock, confirming a failure to timely recognize and act on a significant change in condition.
Surveyors found that the RN designated as the infection preventionist had not completed the required specialized infection prevention and control training. Review of the RN’s training records showed no evidence of IP-specific education, and during interview the RN confirmed she had begun but not finished the required coursework. This was not consistent with the facility’s policy, which requires the IP to be qualified by education, training, certification, or experience and to have completed specialized infection prevention and control training.
A resident with intact cognition and a care plan noting risk for infection due to urinary incontinence developed new hallucinations, severe pain, vomiting, diarrhea, fatigue, refusal of medications, poor intake, and repeated fevers with tachycardia over several days. Despite abnormal vital signs and documented behavioral and neurological changes, staff did not notify the attending MD as required by facility policy and the care plan directive to update the provider as needed. The resident’s condition worsened until she appeared ill, shivering, pale with a grey hue, and reporting pain all over, prompting transfer by ambulance to the ED, where she was diagnosed with sepsis due to E. coli, UTI from an obstructing ureteral stone, acute kidney injury, and septic shock. The attending MD later confirmed she had not been informed of the change in condition and stated she should have been contacted when the resident developed a fever.
The facility did not ensure that all staff completed required annual abuse training and did not effectively track compliance with these requirements. A nursing assistant hired more than a year prior had no documented annual abuse training, and an RN had not completed abuse training since hire, as shown in their training records. The HR manager reported that unit managers were responsible for staff training completion, that corporate sent quarterly notices about required trainings, and that she provided reminders, but she did not monitor which staff had outstanding training. Facility policy required a designated super registrar to manage training tracking, completion of hire courses before independent work on the floor, and quarterly assignment of annual training requirements.
Two residents admitted with indwelling catheters did not receive care in accordance with physician orders when the facility lacked the ordered catheter sizes and appropriate supplies. For one resident with spinal cord injury and bladder dysfunction, staff used tape instead of a Foley clamp during a bath and later replaced a 20 Fr catheter with an 18 Fr catheter because the correct size was not in stock. For another resident with UTI, urinary retention, and chronic kidney disease, staff informed the family that a 14 Fr catheter with a 5 cc balloon was unavailable and inserted a 16 Fr catheter with a 10 cc balloon instead. An RN and the DON reported that admission staff should verify supply availability and that the DON was responsible for ordering supplies; the DON acknowledged that alternate catheter sizes were used without obtaining new physician orders, despite facility policy requiring physician orders to be followed as prescribed.
A resident who had recently undergone hip surgery did not receive timely assessment, monitoring, or documentation of changes in her surgical incision. When signs of infection such as redness, drainage, and pain developed, nursing staff failed to promptly notify the provider or document these changes, despite daily dressing orders. This led to the resident developing a severe infection and sepsis, requiring hospitalization, surgery, and IV antibiotics.
A resident with a recent hip surgery developed signs of infection at the surgical site, including purulent drainage, redness, swelling, and pain. Despite these changes, staff did not consistently document wound assessments or promptly notify the provider, resulting in a delay in medical intervention. The resident was later hospitalized with sepsis and required IV antibiotics and surgical intervention.
Residents lost the ability to perform ADLs without a documented medical reason, as the facility did not ensure that declines in ADL performance were clinically unavoidable or supported by medical documentation.
A resident did not receive appropriate care to maintain or improve ROM and mobility, resulting in a decline that was not attributed to a medical reason.
Grievance forms and procedures were not posted in prominent locations, and residents were unaware of how to file grievances. Staff interviews confirmed that forms were kept behind the nurses' station, requiring residents to ask staff for access, contrary to facility policy stating forms should be readily available.
The facility did not include agency staff hours in its PBJ submissions to CMS because agency staff were not punching in for their shifts, resulting in incomplete and inaccurate direct care staffing data for all residents. This was confirmed by review of timecards and PBJ reports showing low weekend staffing, and acknowledged by both the corporate submitter and administrator.
A resident with severe cognitive impairment and multiple chronic conditions was allowed to self-administer a nebulizer treatment without a completed SAM assessment or physician order. An LPN left the resident unattended during the treatment, contrary to facility policy and care plan directives, and the resident removed the mask and left the room while medication was still being dispensed. Staff interviews confirmed the lack of required assessment and supervision.
A resident with severe cognitive impairment and multiple diagnoses was not assisted with shaving despite visible facial hair and a documented need for staff support with personal hygiene. Observations and staff interviews confirmed the lack of recent assistance, contrary to the resident's care plan and facility policy.
Insufficient Nursing Staffing Led to Delayed Care and Missed Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ assessed needs and provide required care and services. Surveyors found that staffing shortages resulted in delayed toileting assistance, delayed eating assistance, loss of dignity, and transfers performed contrary to assessed needs and facility policy for 2 of 6 residents reviewed. CMS PBJ Staffing Data Reports also showed excessively low weekend staffing triggers for multiple fiscal year quarters. On the day of survey entry, the facility was locked, the survey team had to call for entry, and an LPN stated the facility was working short because a day shift nurse did not show up and the night nurse had stayed until 10:30 a.m. before leaving. The LPN said she had been answering call lights, helping NAs, and trying to complete her own duties, while only two NAs were in the facility. One resident, who had mild cognitive impairment, dementia, non-traumatic spinal cord dysfunction, diabetes, and was dependent on staff for toileting and transfers, was observed crying in bed wearing only a sweatshirt and incontinent brief with no pants. The resident stated staff told her she had to stay in bed and could not get up, and that they told her to pee her pants and they would clean her up there. The resident said this happened all the time and that staff shut off her call light just about every day because they were short. NA-B later cleaned the resident after she was wet and incontinent of urine and feces, applied barrier cream, and then had to leave to get another staff member for a two-person mechanical lift transfer. The resident was then transferred to her wheelchair with two staff and taken to the dining room. Another resident, who was cognitively intact and independent with eating but had been identified as needing assistance with meals for optimal intake, was observed in the dining room with food in front of her and no staff helping her eat. At least two residents were sitting with food in front of them and were not eating or receiving staff assistance. The resident waited 45 minutes before staff assisted her to eat, and once assisted she ate well. Staff interviews described ongoing staffing problems, frequent use of agency staff, missed or late staff, difficulty getting help from float staff, and expectations that medication staff would assist with call lights and resident care when possible. The DON stated float staff lacked accountability because they had no assigned resident group and planned to change assignments so each nursing assistant, including float staff, would have assigned residents.
Infection Prevention and Control Failures With Diarrhea Precautions, Surveillance, and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Surveyors found that transmission-based precautions were not timely initiated or consistently maintained for two residents with potentially infectious diarrhea, that residents with signs and symptoms of possible infection were not consistently tracked through the surveillance system, that hand hygiene was not consistently followed during resident care, and that enhanced barrier precautions were not implemented for residents who met criteria. One resident had loose stools for several days before stool testing confirmed C. diff and norovirus. The record showed provider notification, lab work, and later stool testing, but nursing progress notes repeatedly failed to identify whether contact precautions were in place. When the resident was observed after the positive results, the room had a contact precautions cart and signage, but staff entered and exited the room inconsistently using PPE. One aide entered without PPE, later returned with gown, gloves, and mask, then reentered the room to care for the roommate without gown or gloves. Other staff entered the room without gown or gloves while touching the resident’s personal items, and housekeeping entered with gloves but without a gown. Staff interviews showed inconsistent understanding of when PPE was required and how the room should be managed. A second resident had ongoing loose stools and received repeated doses of loperamide, but the medical record did not identify that contact precautions were started while stool testing was being considered and obtained. The DON stated precautions should have been started whenever a stool panel was requested for a resident with loose stools and should continue until the diarrhea resolved. The surveillance log also failed to capture residents with signs and symptoms of infection that were not treated, and the DON stated an event tracker should have been started for residents with diarrhea and for a roommate exposed to the infected resident. In addition, during care for an incontinent resident, an aide cleaned feces and urine, applied barrier cream, and then used disposable wipes on her gloves without removing them or performing hand hygiene. The report also noted that enhanced barrier precautions were not implemented for two residents who met criteria.
Failure to Include EBP in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included enhanced barrier precautions (EBP) for 3 of 5 residents reviewed who were identified to be on EBP. One resident had intact cognition, required moderate assistance with bathing, had a G-tube, and diagnoses included Parkinson’s disease, narcolepsy, anxiety, and dysphagia. That resident’s care plan addressed incontinence and G-tube care, but did not include instructions for EBP when staff provided G-tube care or personal care. The resident’s active medication orders directed that numerous medications be crushed and administered through the feeding tube, and a sign outside the room directed staff to wear a gown and gloves for direct care, including G-tube care. The DON stated G-tube care was one instance when EBP should be used and that EBP should be care planned when required. A second resident had severe cognitive impairment, obesity, an unstageable pressure ulcer, and moisture associated skin damage. The resident’s wound assessment identified a stable coccyx ulcer, but the care plan lacked any guidance for EBP use. During observation, an isolation cart outside the room had a contact precaution sign for the roommate and did not address whether the resident was on EBP; the cart contained gloves, masks, and eye/face protection, but no gowns. A nursing assistant stated gowns and gloves were not needed for care of that resident and entered the room without wearing either. A third resident had moderate cognition, an indwelling catheter, renal insufficiency, and urinary retention. The care plan included catheter change, daily catheter care, and infection monitoring, but did not include EBP instructions related to the catheter. Observation showed a cart outside the room with gowns and gloves and a sign identifying the resident as on EBP with instructions to wear gowns and gloves for direct care, including catheter care. The DON stated staff were expected to follow resident care plans and the facility policy regarding PPE for EBP.
Failure to Preserve Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to ensure dignified care for one resident who was dependent on staff for toileting and transfers, frequently incontinent of bowel and bladder, and had diagnoses that included dementia, diabetes, non-traumatic spinal cord dysfunction, depression, heart failure, and asthma. Her care plan directed staff to assist her with toileting, provide incontinence care, and offer toileting every 3 hours so she could remain free of skin breakdown and have her dignity respected. She was also documented as being able to verbally ask for toileting assistance and requiring extensive assistance with transfers and toileting needs. During an observation, the resident was found lying in bed wearing only a sweatshirt and an incontinent brief, with no pants and not fully covered by bedding. She was crying and stated staff told her she had to stay in bed and could not get up, and that they told her to pee her pants and they would clean her up in bed. She stated this happened all the time and that nursing assistants shut off her call light just about every day. While she was crying, a nursing assistant entered, said she was wet and needed to be cleaned up, told her not to cry, and then provided incontinent care. During interviews, staff acknowledged the resident should not be told to go in her pants or be encouraged to remain incontinent. One NA stated the resident was encouraged to stay in bed because staff were short and the NA had other residents to care for, and that the resident had asked to get up but was waiting because she required assistance of 2. Other staff stated the resident should never be told to just go in her pants, that residents should not be told to be incontinent, and that such statements were a dignity issue. The DON stated staff were expected to provide care when requested and never tell a resident to be incontinent because it was a dignity issue.
Failure to Investigate and Communicate a Grievance About a Missing Hearing Aid
Penalty
Summary
The facility failed to ensure a resident grievance regarding a missing hearing aid was fully investigated, documented, resolved, and communicated to the resident representative in accordance with facility policy for one resident. The resident’s Customer Concern/Grievance, filed by a family member, reported that the hearing aid was missing. The facility documented an initial search of the room, bedding, and laundry, but no further investigation, follow-up, or resolution was documented. The resident’s progress notes from the date of the grievance through several weeks later contained no documentation about the missing hearing aid or grievance follow-up. During interviews, the SSD acknowledged receiving the grievance but stated it had been assigned to another person and no outcome had been communicated, the family member reported receiving no updates or information after filing the concern, and the DON confirmed there was no documented follow-up and that grievances were expected to be resolved within five days with the complainant updated on progress and outcome.
Failure to Review and Justify Continued PRN Antipsychotic Use
Penalty
Summary
The facility failed to review and justify the continued use of a PRN psychotropic medication for a resident who had moderate cognitive deficit, required moderate assistance with most ADLs, and was under hospice care for end-stage heart failure. The resident’s record showed diagnoses including CHF, dementia, diabetes, and depression, and the quarterly MDS noted no hallucinations, delusions, or behaviors during the observation period. The active physician orders included haloperidol 1 mg every four hours PRN for agitation and restlessness with an open-ended end date. The resident’s care plan identified psychotropic medication use for depression and anxiety, with approaches that included administering medications as ordered and documenting three interventions before giving the PRN medication. The consultant pharmacist twice recommended discontinuing the PRN Haldol because federal guidelines limited PRN antipsychotic orders to 14 days unless the attending physician evaluated the resident for appropriateness of renewal. One recommendation was signed by the physician with a comment that the resident was a hospice patient, but the record did not show a face-to-face provider visit or other documented justification for continued use, and the second recommendation had no physician response documented. The PRN MAR showed Haldol was administered on two occasions during the review period, and the medication order remained open-ended. During observation, the resident was noted hollering that she needed to use the bathroom, then was assisted to a recliner and fell asleep; staff stated she had been up until 3:00 a.m. An LPN stated the Haldol made the resident sleepy and was usually not given during the day so she could eat, while the DON stated PRN psychotropic medications should have a 14-day review and the facility’s policy also limited PRN psychotropic orders to 14 days unless the attending provider evaluated the resident.
Delayed Toileting Assistance and Meal Supervision
Penalty
Summary
The facility failed to provide timely toileting assistance and transfer support for a resident who was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had diagnoses including non-traumatic spinal cord dysfunction, diabetes, and dementia. The resident’s MDS and care assessments identified the need for extensive assistance, including assistance of two for transfers and toileting, use of a full body mechanical lift, peri care after incontinent episodes, and toileting every three hours. During observation, the resident was found lying in bed in an incontinent brief, crying, and stating that staff told her to stay in bed and pee her pants so they could clean her up there. The resident stated this happened all the time and that staff shut off her call light just about every day. The resident remained wet and in bed for an extended period before staff returned to provide care. A nursing assistant later entered, acknowledged the resident was wet, and performed incontinent care, including cleaning feces and urine from the resident’s skin, applying barrier cream, and putting on a clean brief and pants. After care was completed, the nursing assistant had to leave and return with another staff member to complete the transfer using a ceiling lift before the resident was taken to the dining room for lunch. Staff interviews confirmed the resident should not have had to wait when she needed the bathroom and that timely toileting assistance was expected to prevent incontinence and skin breakdown. The facility also failed to provide timely supervision and assistance with eating for another resident who was identified as cognitively intact and independent with eating on the quarterly MDS, but whose nutritional assessment stated the resident normally ate 51-75% of most meals and was assisted with meals for optimal intake. During lunch observation, there was not enough staff in the dining room to assist residents, and at least two residents sat with food in front of them without eating or receiving help. The resident remained seated with a plate of food in front of her for 45 minutes before staff assisted her to eat. Staff interviews indicated the resident had begun to need more help with meals, had started pocketing food, and required supervision and cueing while eating. The DON stated residents who required supervision with eating should be watched closely and assisted in a timely fashion when they stopped eating or had not started eating.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform hand hygiene between glove changes during pressure ulcer wound care for one resident who was cognitively intact, required substantial to maximal assistance with transfers, and had diagnoses including a thoracic vertebra fracture, muscle weakness, and right lower leg amputation. The resident was identified as being at risk for pressure ulcers and had wound orders for the left heel, right buttock, and gluteal crease. The wound assessment described a right upper buttock pressure ulcer measuring 5 cm by 6.5 cm by 2 cm with odor and heavy purulent dark brown drainage saturating the dressings, an unstageable coccyx pressure ulcer, and a deep tissue injury on the left heel with a drained blister and intact epidermal layer. During observed dressing changes, the LPN removed soiled dressings from the right buttock and gluteal fold, then removed dirty gloves and put on new gloves without performing hand hygiene. She repeated this pattern after cleaning the wounds and again while changing the left heel dressing, removing gloves and donning new gloves without hand hygiene before removing the old dressing, cleaning the heel, and applying the new dressing. The LPN stated she washed her hands before starting and after the dressing change, but did not think to perform hand hygiene when changing gloves. The DON stated nurses were to follow wound procedures during dressing changes, including hand hygiene each time gloves were changed, and that hand hygiene was done to ensure the wound does not become decontaminated when placing clean dressings.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Medication Error Not Investigated or Documented
Penalty
Summary
The facility failed to ensure a reported medication error involving Zepbound for a resident with moderate cognitive impairment and diagnoses including morbid obesity, cerebral palsy, and obstructive sleep apnea was investigated, documented, and addressed in accordance with facility policy. The resident’s event report identified a wrong dose on 4/22/26, but the report did not identify any investigation into the event or any actions taken to prevent further events, and the medical record contained no further information about the incident. During interviews, the DON stated there was a lapse in the process and that an investigation was not completed. The DON reported staff explained the medication did not come from the pharmacy and that the resident did not receive the dose, although the event report stated wrong dose. RN-A also stated there was no documentation explaining what occurred or what actions were taken. The consultant pharmacist stated staff were expected to complete a thorough root cause investigation and analysis, with follow-up and detailed documentation for any medication error, including resident assessment, physician notification when indicated, monitoring for adverse effects, and measures to prevent recurrence. The facility policy stated that when a medication error occurs, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation, or treatment is indicated, and that medication errors are tracked and trended for quality improvement purposes.
Unresolved PRN Antipsychotic Order Without Required Provider Evaluation
Penalty
Summary
The facility failed to ensure consultant pharmacist recommendations regarding a psychotropic medication irregularity were addressed for a resident with moderate cognitive deficit, dementia, congestive heart failure, diabetes, and depression who was under hospice care for end-of-life status due to heart failure. The resident’s record showed an active PRN order for haloperidol 1 mg every four hours for agitation and restlessness with an open-ended end date, and the PRN MAR documented administrations on 5/19/26 and 5/26/26. The resident’s care plan noted psychotropic medication use for depression and anxiety, and staff were to document three interventions before giving the PRN medication. Consultant pharmacist recommendation forms dated 3/9/26 and 4/3/26 recommended discontinuing the PRN Haldol because PRN antipsychotic orders were limited to 14 days unless the attending physician evaluated the resident for appropriateness of renewal. The physician signed one recommendation without further response or action, and no physician response was documented for the later recommendation. The medical record lacked a face-to-face assessment by the medical provider to justify continued use of the Haldol, and the facility’s DON stated she believed the regulation had changed for hospice patients. The facility policy also stated PRN psychotropic drug orders were limited to 14 days and could not be renewed unless the attending provider evaluated the resident.
Failure to Recognize and Respond to Resident’s Change in Condition Leading to Sepsis and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to identify and act on a resident’s change in condition despite clear signs of acute illness and a care plan for potential infection. The resident had intact cognition per the annual MDS and no baseline hallucinations, delusions, or behaviors. Her care plan identified a self-care deficit and potential for infection related to urinary incontinence, with directions to update the provider as needed. Beginning several days before hospitalization, progress notes documented new hallucinations and emotional distress, including the resident yelling and crying about her babies being murdered and being taken from her, and an IDT discussion noting hallucinations and behavioral changes. These symptoms were atypical for this resident and represented a change from her baseline. Over the following days, the resident developed and sustained fevers and other signs of systemic illness. Vital signs showed temperatures of 101.7°F with a pulse of 140 bpm, later rising to 103.2°F and remaining elevated around 101–100°F over multiple readings, along with low-grade fevers on subsequent days. Progress notes documented vomiting, visible shaking, feeling cold, episodes of incontinent diarrhea, reports of pain “everywhere,” crying, tearfulness, fatigue, and refusal of medications and meals. Despite these findings, nursing staff treated the resident only with scheduled acetaminophen and did not conduct a documented comprehensive nursing assessment or notify the provider when the fevers and other symptoms emerged and persisted. The IDT discussed the resident’s fevers, fatigue, medication refusals, and verbal behaviors but did not review the progress notes or vital signs in detail, and no provider notification occurred at that time. Staff interviews further confirmed that the change in condition was not appropriately recognized or escalated. One RN stated she had not identified anything out of the ordinary beyond weakness and a presumed low-grade influenza, and that staff believed the resident might be recovering when a single temperature reading was normal. Another RN acknowledged that the resident’s change in condition occurred over a weekend when the IDT was not present and that the team did not review the progress notes or vital signs during the subsequent IDT meeting. A different RN reported that she did not assess the resident after the IDT discussion because the resident was asleep and her temperature had decreased slightly, and she felt that the resident’s bipolar diagnosis and prior behaviors had masked the change and interfered with judgment. The facility’s own policy required licensed nurses to evaluate significant changes in condition, obtain vital signs, and notify the provider of abnormal vital signs, behavioral or neurological changes, and worsening pain, but this process was not followed for this resident, resulting in delayed recognition and treatment of sepsis and subsequent hospitalization. Ultimately, the resident was sent to the ED only after she appeared pale with a grey hue, had dark circles under her eyes, was shivering, reported generalized pain, and continued to feel unwell. In the ED, she was found to be ill-appearing and toxic-appearing, with a high fever, tachycardia, hypotension, low GFR, and a diagnosis of sepsis with acute renal failure, septic shock, acute kidney injury, ureteral obstruction, and UTI. The attending MD later stated that the facility had not contacted her when the resident developed a fever and that earlier evaluation could have avoided the septic shock. The NP who saw the resident in the ED described her as barely responsive, with low blood pressure requiring IV fluids and vasopressors, and indicated that while the ureteral stone itself was not avoidable, the sepsis and unnecessary pain could have been prevented if the resident had been sent to the ED sooner. These facts support the finding that the facility failed to provide appropriate treatment and care according to orders, the resident’s preferences and goals, and its own change-in-condition policy.
Removal Plan
- Review policies and procedures related to change in condition and physician notification.
- Review all residents for a potential change in condition.
- Educate nursing staff on policies and procedures related to change of condition and resident monitoring, qualifying factors for a change of condition, assessment of resident symptoms without bias, and timely physician notification and treatment of resident symptoms.
Designated Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) completed the required specialized training for directing the infection prevention and control program. Surveyors’ review of the personnel training record for a registered nurse identified as the facility’s IP showed no evidence of training related to the IP role. In an interview, the RN confirmed she was the designated IP, stated she had started the required training, but acknowledged she had not had time to finish it. The facility’s policy titled “Infection Preventionist Role,” dated 8/2023, specified that the IP or designee is responsible for directing the infection prevention and control program and should have appropriate background and training, be qualified by education, training, certification or experience, and have completed specialized training in infection prevention and control. This lack of completed specialized IP training for the designated RN, as documented in records and confirmed in interview, was inconsistent with the facility’s own policy requirements for the infection preventionist role.
Failure to Notify Physician of Resident’s Significant Change in Condition Leading to Hospitalization for Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a resident’s significant change in condition despite multiple abnormal findings and behavioral changes. The resident had intact cognition, was care planned for potential infection related to urinary incontinence, and was described as alert, oriented, and independent in decision-making. Over several days, progress notes documented new hallucinations, delusions, crying, and verbal outbursts, including statements about murdering her babies and fears about her babies being taken away. The IDT discussed these behaviors and noted hallucinations. Concurrently, the resident reported vomiting all night, severe pain, and feeling unable to move. Vital signs showed repeated fevers, including temperatures over 101°F and up to 103.2°F, along with tachycardia over 100 bpm. The resident also experienced incontinent diarrhea, generalized pain, fatigue, refusal of medications, and poor oral intake. Despite these documented changes—abnormal vital signs, new behavioral and neurological symptoms, worsening pain, and functional decline—there was no evidence that staff notified the attending physician of the change in condition, even though the care plan directed staff to update the provider as needed and facility policy required provider notification for significant changes and abnormal findings. The IDT noted the resident’s fevers and behaviors and planned to assess and contact the provider “if necessary,” but the physician later confirmed that staff had not contacted her when the resident developed a fever and other symptoms. The resident was eventually noted to be shivering, pale with a grey hue, with dark circles under her eyes, reporting pain all over and not feeling well, at which point an ambulance was called and she was sent to the ED, where she was diagnosed with sepsis due to E. coli with acute organ dysfunction, septic shock, UTI secondary to an obstructing ureteral stone, and acute kidney injury. The physician and another MD interviewed both stated that they had not been notified of the change in condition and that they should have been contacted when the resident developed a fever.
Failure to Ensure and Track Completion of Annual Abuse Training for Staff
Penalty
Summary
The facility failed to ensure completion and tracking of required annual abuse training for staff, resulting in two of ten staff reviewed not having current abuse education. A nursing assistant hired on 11/7/25 had no record of completed annual abuse training as of a training record printed on 3/5/26. A registered nurse hired on 8/28/24 had not completed annual abuse training since the date of hire, according to a training record printed on 3/5/26. During an interview, the human resources manager stated that managers were responsible for ensuring their staff completed training, that the corporate office sent quarterly messages regarding required trainings, and that she reminded managers, but she did not track which staff had or had not completed required training. The facility’s Regulatory and Compliance Education policy dated 5/1/24 stated that each community should assign an associate to the super registrar role to manage tracking of the training system, that assigned hire courses should be completed before an associate works independently on the floor, and that annual requirements are established and assigned quarterly.
Failure to Follow Physician Orders for Catheter Supplies and Sizes
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders by not having the correct catheter supplies available upon admission and by using alternate catheter sizes without physician orders for two residents with indwelling catheters. One resident with a spinal cord injury, neuromuscular bladder dysfunction, and depression was admitted with an order for catheter changes every four weeks and as needed, and a care plan identifying a urinary catheter for obstructive uropathy. Progress notes documented that staff did not have a Foley catheter clamp available when the resident requested a tub bath, so they used tape to kink and clamp the catheter. Later, when attempting to flush the catheter, staff found it plugged and discovered the correct catheter size was not in stock. The resident had a 20 French catheter with a 10 cc balloon in place, but staff replaced it with an 18 French catheter with a 10 cc balloon instead of the ordered size. A second resident admitted with diagnoses including UTI, urinary retention, and chronic kidney disease had a physician order for a one-time insertion of a 14 French catheter with a 5 cc balloon. Progress notes indicated that staff informed the family they did not have a 14 French catheter available and therefore replaced it with a 16 French catheter with a 10 cc balloon. Interviews with an RN and the DON revealed that the person entering admission orders was expected to check supply availability and that the DON was responsible for ensuring the correct catheter sizes were in stock. The DON acknowledged that the correct catheter size was not available for the first resident at admission, that a different size was used without obtaining a physician order, and that she was not aware the correct size was also unavailable for the second resident. Facility policy stated that all physician orders were to be followed as prescribed and that any orders not followed should be documented in the medical record during that shift; the facility’s policy on physician notification of changes in orders was requested but not provided.
Failure to Assess, Monitor, and Report Surgical Site Infection
Penalty
Summary
The facility failed to ensure that a resident received necessary medical attention and comprehensive assessment following a change in her left hip surgical incision. After undergoing surgery for a left subtrochanteric femur fracture, the resident's incision was initially documented as healing well, with no drainage or pain. However, after staple removal, there were periods where no documentation was made regarding the incision, and when changes such as redness, purulent drainage, and tenderness were observed, these were not promptly reported to the provider. Nursing staff did not consistently assess, monitor, or document the condition of the surgical site, despite orders for daily dressing changes and assessments. When signs of infection, including purulent drainage, erythema, and pain, were noted, there was a lack of timely communication with the provider. Nursing assistants reported changes to the nursing staff, but these concerns were not documented or escalated as required. The provider was not notified immediately when infection indicators appeared, and documentation of assessments and interventions was inconsistent. Interviews with staff confirmed that the expected protocol was not followed, and that the provider should have been contacted as soon as infection was suspected. As a result of these failures, the resident developed a post-surgical abscess and sepsis, requiring hospitalization, surgery, and the insertion of a PICC line for IV antibiotics. The hospital records indicated that the infection had progressed significantly by the time of transfer, and staff interviews acknowledged that earlier recognition and intervention could have prevented the escalation. Facility policies required daily assessment and documentation of wounds, as well as prompt provider notification for signs of infection, but these were not adhered to in this case.
Failure to Promptly Notify Provider of Post-Surgical Infection
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician of a significant change in a resident's condition following hip surgery. The resident, who had a history of a left subtrochanteric femur fracture treated with open reduction and internal fixation, developed signs of infection at the surgical site, including purulent drainage, erythema, swelling, and pain. Documentation shows that from 8/27 through 8/31, there was no recorded assessment of the surgical incision, despite daily dressing changes being required. On 9/1, the resident exhibited clear signs of infection, such as purulent drainage and tenderness, but there was no evidence that a provider was notified at that time, nor was this action documented. Nursing staff and nursing assistants observed and reported changes in the resident's incision, including increased redness, drainage, and pain, to the nurse on multiple occasions. However, these observations were not consistently documented, and the provider was not contacted promptly. Interviews with staff confirmed that the expected protocol was to notify a provider immediately when signs of infection were present, such as purulent drainage, redness, and pain. The provider was not contacted until several days after the initial signs of infection appeared, and only after the resident's condition had further declined, resulting in the need for hospital transfer. The resident was ultimately hospitalized with a diagnosis of sepsis due to a post-surgical abscess, requiring intravenous antibiotics and surgical intervention. Facility policy required daily assessment and documentation of wounds, as well as immediate provider notification upon identification of infection signs. The failure to assess and document the surgical site daily, combined with the delay in notifying the provider of significant changes, directly contributed to the deficiency identified in the report.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care and services were provided to prevent a decline in the resident's physical abilities, except in cases where such decline was due to a documented medical reason. This resulted in the resident experiencing a decline in ROM or mobility that was not medically justified.
Grievance Forms Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms and procedures were posted in prominent locations throughout the building, making it difficult for residents and their representatives to file grievances, including anonymously. During a resident council meeting, five residents reported being unaware of how to file a grievance form. Subsequent observation by the surveyor confirmed that grievance forms were not visible or accessible in common areas of the facility. Interviews with facility staff, including the social worker and administrator, revealed that grievance forms were kept behind the nurses' station, requiring residents to request them from staff rather than accessing them independently. The facility's posted grievance procedure encouraged residents to notify the nurse in charge or contact specific facility leaders if concerns could not be resolved, and the policy stated that concern forms should be readily available. However, these forms were not accessible as described, and residents were not informed of their location or how to use them.
Failure to Accurately Report Agency Staffing Data in PBJ Submissions
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for the first quarter reviewed. Specifically, agency staff were not punching in for their shifts, resulting in their hours not being included in the Payroll Based Journal (PBJ) submissions. This omission was confirmed through a review of agency staff timecards and the PBJ report, which identified excessively low weekend staffing. The corporate submitter responsible for PBJ submissions acknowledged that she was unaware of the low weekend staffing trigger and confirmed that agency staff who did not punch in were excluded from the PBJ data sent to CMS. The administrator also verified that agency staff had not been punching in during the first quarter, which led to incomplete staffing data being reported. The facility's policy required that all direct care staffing information, including agency and contracted staff, be submitted to CMS according to the specified schedule. The failure to ensure agency staff were properly recorded resulted in inaccurate staffing information being reported for all 39 residents in the facility.
Failure to Assess and Supervise Self-Administration of Nebulizer Medication
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including Alzheimer's disease, diabetes mellitus, and hypertension was observed self-administering a nebulizer treatment without having been assessed for the ability to safely self-administer medications. The resident required extensive assistance with bed mobility, transfers, toileting, and personal hygiene, and there was no completed self-administration of medications (SAM) assessment or physician order permitting self-administration in the resident's electronic health record. The care plan directed staff to administer all medications as ordered by the physician. During observation, an LPN prepared and placed the nebulizer mask on the resident and then left the room, leaving the resident unattended. The resident subsequently removed the mask with medication still being dispensed and left the room, leaving the nebulizer mask on the bed. Interviews with the LPN, RN, and DON confirmed that no SAM assessment had been completed and that staff were expected to remain with the resident during nebulizer administration in the absence of such an assessment or physician order. Facility policy required nurses to assess each resident's mental and physical abilities before permitting self-administration of medications.
Failure to Provide Assistance with Personal Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and diagnoses including dementia, diabetes mellitus, and hypertension was not provided with necessary assistance for personal hygiene, specifically shaving facial hair. The resident's care plan and assessments indicated a need for staff assistance with grooming and personal hygiene due to deficits related to dementia and physical limitations. Observations on two consecutive days revealed the resident had several half-inch long gray facial hairs on her chin, upper lip, and around her mouth. Interviews with a family member confirmed the resident's preference to be shaved when facial hair was visible. Further interviews with facility staff, including a nursing assistant and a registered nurse, confirmed that the resident required staff assistance for shaving and had not been recently assisted. The nursing assistant was unsure of the last time the resident had been shaved, and both the registered nurse and the director of nursing stated their expectation that the resident should have been shaved as soon as facial hair was present. Facility policy required that residents unable to perform activities of daily living independently receive necessary services to maintain good personal hygiene, in accordance with their care plans.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Halstad Living Center | 14.1 mi | ★★★★★ | 6 | 0 |
| Viking Manor Nursing Home | 19.6 mi | ★★★★★ | 0 | 0 |
| Fair Meadow Nursing Home | 19.8 mi | ★★★★★ | 12 | 0 |
| Sanford Hillsboro Care Center | 25.7 mi | ★★★★★ | 0 | 0 |
| Mahnomen Health Center | 26.1 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Benedictine Care Community.
100% money-back within 48 hours.
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.