Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Living Community Mother Of Mercy during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, poor safety awareness, impaired vision/hearing, and a history of falls was left with access to a power lift recliner without a completed safe-use assessment. She attempted to self-transfer from the chair, fell, and sustained a forehead laceration and hematoma requiring ED care and sutures. She later had another fall from a wheelchair and developed a large hematoma to the hip/thigh area, again requiring ED evaluation. Staff and family described her as confused, impulsive, and unable to safely use the lift chair remote.
The facility failed to properly store, label, date, and discard food items. During observation, multiple opened refrigerated foods lacked open or expiration dates, mold was seen on a package of hamburger buns, and several frozen items were stored on the floor or left uncovered. The culinary services manager acknowledged that opened food and leftovers should be dated, bread should be discarded if undated after opening, and frozen foods should not be stored on the floor. The facility also had missing refrigerator and freezer temperature logs for the kitchen units and multiple resident unit refrigerators.
The facility failed to provide required Medicare coverage notices for two residents whose Part A skilled services were ending. One resident with chronic respiratory failure, UTI, and HTN did not have evidence of a NOMNC when Part A ended, and another resident with a vertebral compression fracture, cancer, CAD, and arthritis did not have evidence of an ABN when Part A ended and the resident remained in the facility.
Failure to Conduct Required Care Conference: The facility did not conduct a care conference for a resident who was cognitively intact and had diagnoses including HTN, arthritis, malnutrition, anxiety, bipolar disorder, and schizophrenia. The resident had no recollection of any care conference being offered or held, the chart had no evidence of one, and the SW and DON both confirmed none had been offered or conducted.
A resident with multiple chronic conditions, including HF, DM, HLD, dementia, and BPH, went without several ordered medications because the facility did not ensure the pharmacy had the needed coverage information and signed orders after the resident’s insurance changed. The MAR showed missed administrations of multiple meds, and staff notes and interviews confirmed delays involving VA communication, pharmacy follow-up, and no process in place at the time to prevent the lapse in medication supply.
Improper Disinfection of Shared Glucometer: A nursing student used a shared glucometer to check a resident’s blood glucose and then wiped the device for about 20 seconds instead of allowing the germicidal wipe to remain wet for the required 2 minutes. The resident had diabetes and was cognitively intact. The nursing instructor confirmed the student was supervised during the task, and the IP and DON stated shared glucometers must be disinfected according to the manufacturer’s instructions between residents.
Two residents with heart failure were inadequately monitored, leading to one being re-hospitalized. The facility failed to follow physician orders for weight monitoring and PRN Lasix administration, resulting in significant weight gain and edema. Despite recommendations to clarify medication orders, the facility discontinued the PRN Lasix without proper authorization, contributing to the deficiency in care.
The facility failed to post accurate daily staffing information, affecting all 57 residents and their visitors. From 11/17/24 to 12/20/24, postings lacked details on the number of licensed staff and hours worked. The DON admitted to incorrect postings due to miscommunication, and the information was not updated on weekends. No policy was provided.
The facility failed to conduct a comprehensive facility-wide assessment, missing critical components such as facility information, quality assurance input, and contingency staffing plans. The administrator acknowledged the importance of the assessment for guiding staffing and resident care needs, but the document provided was incomplete, potentially affecting all 57 residents.
The facility's QAPI program was ineffective, failing to identify and address quality deficiencies, including communication of medication changes, bed-hold notices, and heart failure interventions. A resident was re-hospitalized due to exacerbation of heart failure. The facility lacked comprehensive assessments and proper hand hygiene practices. Meeting documentation was insufficient, and there was a delay in addressing known issues.
A facility failed to ensure a resident's advanced directives were accurately reflected in their medical records. The resident's POLST indicated a DNR status, but the EMR banner showed FULL CODE. This discrepancy was discovered by a nurse manager and confirmed by the DON, highlighting a failure to ensure the resident's wishes were documented correctly for emergency situations.
A facility failed to provide a written bed-hold notice during two hospital transfers for a resident with multiple health conditions, including dementia and CHF. Verbal consent was obtained from the family, but no written notice was given, contrary to the facility's policy requiring written information at the time of transfer or within 24 hours for emergencies.
The facility failed to complete and transmit a discharge MDS for two residents, one with osteoarthritis and another with hyponatremia, due to communication lapses. The MDS nurse, working offsite, did not receive necessary updates on resident discharges, and the DON noted a lack of involvement in MDS processes. The policy for MDS submissions was not provided, highlighting procedural gaps.
The facility failed to ensure proper hand hygiene during medication administration and handling of soiled clothing. An RN and an LPN did not perform hand hygiene between tasks and residents, while a nursing assistant carried soiled clothing without bagging it or wearing gloves. These actions were contrary to infection control standards and acknowledged by the staff involved.
A facility failed to provide a pneumococcal vaccine in a timely manner to a resident. The resident's MDS indicated they were not up to date with vaccinations, and a consent form was signed and uploaded to the EMR. The DON was unsure of the immunization process, and the IP, who reviewed immunization status using MIIC and an app, confirmed the vaccine was not administered by the expected date.
A facility failed to notify a resident's representative about the discontinuation of a PRN Lasix prescription for CHF-related edema. Despite the resident's significant medical conditions, including dementia and CHF, the family was not informed of the medication change, which was confirmed by the DON. This oversight violated the facility's policy on promptly notifying changes in medical care.
The facility failed to notify and consult the provider for two residents with heart failure monitoring needs. One resident did not receive prescribed Lasix for weight gain, and another had multiple missed weigh-ins without provider notification. The DON confirmed the nursing staff's responsibility to document and communicate concerns, which was not adhered to, leading to the deficiency.
The facility failed to update care plans for two residents with heart failure. One resident's care plan lacked updates for monitoring lung congestion and weight gain, while another's care plan did not reflect the required frequency of weight monitoring. Interviews with the DON confirmed the care plans were not updated as expected, which is essential for preventing acute exacerbations of heart failure.
A resident experienced a critical low potassium level due to missed medication doses, as the facility failed to notify the physician about the unavailability of potassium supplements. Despite knowing the medication was not available, staff did not contact the physician for guidance, leading to a critical drop in potassium levels and the need for emergency medical services.
A resident missed 10 doses of potassium due to the facility's failure to ensure timely administration, resulting in a critically low potassium level and an emergency room visit. The resident, recently discharged from the hospital, experienced a drop in potassium levels after starting a diuretic. Despite multiple faxes to the pharmacy, the medication was not delivered, and staff failed to notify the provider or follow up adequately.
The facility failed to implement effective infection control measures during a renovation project, leading to the spread of dust and potential mold exposure. The project was not overseen by a licensed contractor, and CDC guidelines were not followed. Immunocompromised residents were not relocated or monitored, and communication among staff was inadequate.
A resident with severe environmental allergies experienced significant health issues due to inadequate precautions during facility renovations. The care plan lacked necessary information on her allergies, and staff were not properly informed, leading to repeated exposure to allergens. Despite being offered measures like an N95 mask and supplemental oxygen, the resident declined a room change, believing odors were pervasive. The facility's failure to update the care plan and ensure staff awareness resulted in ongoing distress for the resident.
Failure to Assess Safe Use of Power Lift Recliner
Penalty
Summary
The facility failed to assess whether a resident with severe cognitive impairment could safely use an electric lift recliner independently. The resident had multiple conditions including renal insufficiency, arthritis, osteoporosis, macular degeneration, encephalopathy, and kyphosis, and was dependent on staff for most transfers and ADLs. Admission and therapy documentation identified poor safety awareness, short-term memory loss, impaired vision and hearing, confusion, and a history of falls. The care plan and therapy notes repeatedly stated that lift recliner use was not recommended or that the power function should not be used, but the resident remained in the chair with access to the remote before a safe-use assessment was completed. The resident attempted to self-transfer from the power lift chair, fell, hit her head, and sustained a forehead laceration and hematoma. She was sent to the ED, where the laceration was repaired with four sutures and imaging showed no acute intracranial injury. Facility documentation described the resident as confused, impulsive, and unable to make safe decisions, with staff noting that she self-transferred and did not consistently use the call light. The report also states that the admitting nurse and therapy were expected to assess safe use of the lift recliner upon admission, but that assessment was omitted during the admission process. The resident later had another fall from a wheelchair after staff and family had placed her feet on a chair or other stationary item while she sat in the room. She was found on the floor with pain and a large hematoma to the right lateral thigh/hip area and was again sent to the ED, where no fracture or intracranial hemorrhage was found. Interviews with staff and family described the resident as forgetful, confused, and unable to safely use the lift chair remote, and family stated the resident had previously nearly fallen while using the remote. The report also documents that the resident had a prior history of falls and fractures, and that she required close assistance for transfers and supervision due to her cognitive and mobility limitations.
Improper Food Storage, Labeling, and Temperature Monitoring
Penalty
Summary
The facility failed to ensure food items were properly stored, labeled, dated, and discarded. During a kitchen walk-through with the licensed dietician, multiple items in the walk-in cooler were observed without open or expiration dates, including opened hard salami, cheesecake, cole slaw, green beans, sliced cooked potatoes with cream sauce, and three bean salad. In the walk-in freezer, two open cases of sweet potato fries and one open case of chicken and dumplings were stored on the floor, and an open bag of chicken patties and an uncovered container of pureed berries lacked open or expiration dates. Outside the cooler, a package of hamburger buns had visible mold, an open package of King's Hawaiian rolls lacked a date, and an open package of hot dog buns had a handwritten date that could not be identified as an open date or expiration date.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) forms were provided to residents whose Medicare Part A services were ending for 2 of 3 residents reviewed. One resident was admitted with chronic respiratory failure, urinary tract infection, and high blood pressure; the record showed the last covered day of Medicare Part A service was 9/8/25 and the resident was discharged, but the medical record lacked evidence that a NOMNC was issued. A second resident was admitted with a wedge compression fracture of the vertebrae, cancer, coronary artery disease, and arthritis; the record showed the last covered day of Medicare Part A services was 1/29/26 and the resident remained in the facility, but the medical record lacked evidence that an ABN was issued.
Failure to Conduct Required Care Conference
Penalty
Summary
The facility failed to conduct care conferences for 1 of 2 residents reviewed for care planning, identified as R27. R27’s admission MDS showed the resident was admitted on [DATE], was cognitively intact, and had diagnoses including hypertension, arthritis, malnutrition, anxiety, bipolar disorder, and schizophrenia. During screening, R27 stated there was no recollection of any care conferences being offered or conducted since admission. The medical record contained no evidence that a care conference was ever offered or conducted. The social worker stated care conferences were expected with quarterly and annual MDS assessments or with a change in condition, and confirmed none had been offered or conducted for R27. The DON also confirmed no care conference had been offered or conducted and stated they were important to include the whole team, review the chart, involve family, gain outside input, and include the information in the care plan.
Medications Not Available After Coverage Change
Penalty
Summary
The facility failed to ensure medications were available for administration per physician order for one resident who had diagnoses including acute respiratory failure, DM, vitamin D deficiency, HLD, dementia, neurocognitive disorder with Lewy bodies, HF, asthma, ischemic cardiomyopathy, BPH, and a coronary angioplasty implant and graft. The resident’s MAR showed that several ordered medications, including amlodipine, empagliflozin, metformin, mirabegron, rosuvastatin, sertraline, tamsulosin, and torsemide, were not administered from 5/23/25 through 5/28/25. The record also showed the resident’s Medicare coverage ended on 5/14/25, and progress notes documented that VA had been notified about the lack of coverage and that a list of medications was sent to VA for refills. During the same period, the record documented that the provider was updated that metformin and tamsulosin were not being taken due to no supply, and the facility was in contact with VA to get medications refilled, with VA requesting more information before filling the medications. The RN manager stated the facility would normally contact the pharmacy and provider if medications ran out, and recalled that the resident had come off skilled care and no longer had coverage for medications. The consultant pharmacist stated the pharmacy had faxed the facility that signed provider orders were needed to fill the medications, and the administrator, SW, DON, and regional clinical leadership confirmed there was no process in place at the time to notify the pharmacy of the coverage change and that the resident went without medications during the identified period.
Improper Disinfection of Shared Glucometer
Penalty
Summary
The facility failed to properly sanitize a shared glucometer after it was used to check a resident’s blood glucose. The resident had diabetes and anxiety disorder, and the quarterly MDS indicated the resident was cognitively intact. The resident’s order summary showed finger stick blood glucose checks every shift. During observation, a nursing student used a glucometer from the medication cart to check the resident’s blood sugar and then wiped the device with a germicidal surface wipe for about 20 seconds before returning it to the drawer. The nursing student later confirmed she did not allow the disinfectant the proper contact time and read the wipe label, which stated surfaces must remain wet for 2 minutes. The nursing instructor stated she supervised the nursing student during the task and confirmed the glucometer was not disinfected for the required contact time. The infection preventionist stated residents should have their own personal glucometers, but the facility kept one on the medication cart as a backup, and that the glucometer should have been disinfected according to the manufacturer’s instructions. The DON confirmed that shared glucometers should be cleaned and disinfected between residents, that staff are educated upon hire, yearly, and as needed, and that nursing students should be supervised at all times while performing nursing tasks. The facility stated it would follow the user manual for disinfecting.
Failure to Monitor and Implement Heart Failure Interventions
Penalty
Summary
The facility failed to adequately monitor and implement interventions for heart failure in two residents, resulting in actual harm to one resident who was re-hospitalized due to exacerbation of heart failure. The resident, who had a history of dementia, chronic diastolic congestive heart failure (CHF), diabetes, and other conditions, was prescribed furosemide (Lasix) 20mg daily as needed for lung congestion and lower extremity edema. However, the facility did not contact the cardiologist for specific parameters for administering the PRN diuretic, nor did they monitor the resident for signs of lung congestion and edema as required. The resident's records showed multiple instances where weight gain and edema were not properly assessed or reported to the provider, and the PRN Lasix was not administered according to the prescribed parameters. Despite recommendations from the pharmacist to clarify the PRN Lasix order, the facility discontinued the medication without proper authorization or clarification from the provider. This lack of monitoring and communication led to the resident experiencing significant weight gain and edema, ultimately resulting in hospitalization for acute exacerbation of CHF. Another resident with a history of acute on chronic congestive heart failure and other cardiac conditions also experienced inadequate monitoring. The facility failed to consistently obtain and document weights as ordered, missing numerous opportunities to monitor the resident's condition. Despite the resident's reports of weight gain and tighter legs, the facility did not notify the provider of missed weights or changes in the resident's condition. This lack of adherence to physician orders and failure to communicate critical information contributed to the deficiency in care for both residents.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the required staffing information was posted daily, which had the potential to affect all 57 residents and their visitors. Upon entrance on 12/16/24 and 12/17/24, the staff postings were observed to include licensed staff and total hours worked. However, from 11/17/24 through 12/20/24, the postings lacked accurate information regarding the number of licensed staff working each day, the hours worked, and the total hours of all licensed staff. On 12/20/24, the Director of Nursing (DON) acknowledged that the information on the staff postings was incorrect due to miscommunication and that the information had been lost. The DON and the HR manager confirmed that the daily staffing sheets were incorrect or missing and were not updated in person on weekends. Additionally, the facility was unable to provide a policy regarding the posting of staffing information.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment necessary for providing adequate care and services to its residents. During the entrance conference, the survey team requested the facility assessment, which was not provided within the stipulated time. Subsequent requests were made, and eventually, the administrator sent an incomplete Facility Assessment Tool. The document, dated September 5, 2024, lacked critical components such as the facility's information, input from the quality assurance team, and a list of personnel involved in the assessment. Additionally, it did not include a contingency staffing plan, staff competencies, and health information technology resources. The administrator confirmed their responsibility for creating the facility assessment and acknowledged the importance of its completion in guiding staffing, equipment, and resident care needs. However, the assessment was incomplete, and no facility assessment policy was provided upon request. This deficiency had the potential to affect all 57 residents in the facility, as it indicated a lack of preparedness in both day-to-day operations and emergency situations.
Ineffective QAPI Program Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Assessment/Quality Assurance and Performance Improvement (QAA/QAPI) program, which resulted in several deficiencies. The facility did not conduct ongoing quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct repeated quality deficiencies. These deficiencies included failing to communicate medication changes to residents or their representatives, not providing written notice of a bed-hold during hospital transfers, and failing to monitor and implement interventions for heart failure, which led to the re-hospitalization of a resident. Additionally, the facility did not conduct a comprehensive facility-wide assessment and failed to ensure appropriate hand hygiene during medication pass and while handling soiled clothing. The facility's QAPI meeting minutes for the past 12 months were not adequately documented, with only one meeting agenda provided, which did not address previous survey results or current performance improvement projects. Interviews with the Director of Nursing (DON) and the administrator revealed awareness of ongoing quality of care issues, such as staff obtaining and documenting resident weights, but there was a delay in providing staff education or training. The administrator mentioned that the facility held monthly QAA meetings and quarterly QAPI meetings, but no monthly meeting minutes were provided, and the QAPI agenda lacked evidence of the reported performance improvement projects.
Failure to Accurately Reflect Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that a resident's advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart. This deficiency was identified for a resident who was moderately cognitively impaired and had multiple diagnoses, including hypertension, arthritis, osteoporosis, and asthma. The resident's Provider Orders for Life-Sustaining Treatment (POLST) indicated a Do Not Attempt Resuscitation (DNR) status, signed by the healthcare agent and a physician's assistant. However, the electronic medical record (EMR) banner incorrectly displayed the resident's resuscitation status as FULL CODE. The discrepancy was discovered when the registered nurse manager (RN-D) reviewed the resident's code status and found that the EMR banner did not match the POLST. The director of nursing (DON) confirmed that the EMR banner and POLST form did not match prior to the survey start. The facility's policy required that resuscitation orders be reviewed upon admission and verified with the POLST. The inconsistency in the resident's resuscitation status was noted to have been corrected after the survey entrance, indicating a failure to ensure the resident's wishes were accurately documented and could be implemented correctly in an emergent situation.
Failure to Provide Written Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of a bed-hold at the time of transfer for a resident who was hospitalized on two separate occasions. The resident, who had a significant change in their Minimum Data Set (MDS) indicating diagnoses of dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation, peripheral neuropathy, and diabetes, was transferred to the hospital for increased redness and swelling in the left foot and later for increased pain and a change in transfers. In both instances, verbal consent for a bed-hold was obtained from the resident's family member, but there was no evidence that a written bed-hold notice was provided to the resident or their representative at the time of transfer. The facility's Bed-Holds and Returns Policy, revised in October 2022, required that residents or their representatives be provided with written information regarding bed-hold policies at the time of transfer or within 24 hours for emergency transfers. Despite this policy, the facility did not provide the necessary written documentation during the resident's transfers on both occasions. The Director of Nursing (DON) confirmed that the written bed-hold information was not provided as required, emphasizing the importance of such documentation to ensure residents and their representatives understand their rights and the implications of a bed-hold.
Failure to Complete and Transmit Discharge MDS for Two Residents
Penalty
Summary
The facility failed to complete and transmit a discharge return not anticipated Minimum Data Set (MDS) for two residents, leading to a deficiency in the transmission of resident assessments. Resident 25, who was cognitively intact and had a primary diagnosis of osteoarthritis with a joint replacement, was discharged without a completed discharge MDS. Similarly, Resident 48, who was also cognitively intact and had a primary diagnosis of hyponatremia, left the facility without a completed discharge MDS. The medical records for both residents lacked evidence of the required discharge MDS completion. The MDS registered nurse, who worked offsite, confirmed that she relied on the facility to update her on admissions, discharges, or significant changes in residents' conditions. She acknowledged that the discharge MDS was not completed for both residents, possibly due to a lack of updates from the facility. The Director of Nursing, who had limited involvement with MDS completion and submission, mentioned that there was a leadership email group intended to provide updates on resident status changes, which the MDS nurse should have been part of. However, the policy for MDS submissions was requested but not provided, indicating a potential gap in communication and procedural adherence within the facility.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration and handling of soiled clothing, which could potentially affect all 57 residents, staff, and visitors. During a medication pass, an RN did not wash hands or use alcohol-based hand sanitizer after administering medication to a resident and before preparing medication for another resident. Similarly, an LPN did not perform hand hygiene after removing gloves following a blood sugar check and insulin administration, and before handling medication for another resident. Both staff members acknowledged the oversight during interviews, with the RN stating she intended to use hand sanitizer and the LPN admitting she forgot to do so. Additionally, a nursing assistant was observed carrying soiled clothing without placing it in a bag and without wearing gloves, as required by infection control standards. The nursing assistant confirmed the clothing should have been bagged before being removed from the resident's room. The infection preventionist stated that staff were expected to bag soiled items and wear gloves to prevent the spread of infection. The facility's policy on handling soiled clothing was requested but not provided.
Failure to Timely Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccine in a timely manner to one resident reviewed for immunizations. The resident's admission Minimum Data Set (MDS) indicated that they were not up to date with pneumococcal vaccinations. A consent form for the vaccination was signed by the resident and uploaded to the electronic medical record within the same week as admission. However, the Director of Nursing was unsure of the process for reviewing and administering immunizations, deferring to the infection preventionist. The infection preventionist stated that she reviewed immunization status upon admission using the Minnesota Immunization Information Connection and used an app recommended by the facility pharmacy to determine vaccine eligibility. Despite these steps, the immunization was not received and administered by the expected date.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to ensure that changes in medication were communicated to a resident's representative, leading to a deficiency in the notification of change in medications. The resident, who had a significant change in their Minimum Data Set (MDS), was diagnosed with dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation, peripheral neuropathy, and diabetes. A cardiology clinic note indicated that the resident was prescribed furosemide (Lasix) 20mg daily as needed for lung congestion and lower extremity edema related to CHF. However, the medication was discontinued without notifying the resident's representative. The resident's family member, who accompanied them to the cardiologist, was not informed of the discontinuation of the PRN Lasix. This lack of communication was confirmed by the Director of Nursing (DON), who acknowledged that the progress notes failed to indicate that the family had been notified of the medication change. The facility's policy required prompt notification of any changes in medical care or nursing treatments, which was not adhered to in this case, resulting in a deficiency.
Failure to Monitor and Notify Provider for Heart Failure Management
Penalty
Summary
The facility failed to notify and consult the provider for two residents with heart failure monitoring needs. Resident R33 had a significant change in condition, with diagnoses including dementia, chronic diastolic congestive heart failure, atrial fibrillation, peripheral neuropathy, and diabetes. Despite having a physician's order for Lasix 20mg to be administered as needed for specific weight gains, the medication was not given on two occasions when the resident experienced weight gains that met the criteria. The registered nurse confirmed the failure to administer the medication as ordered. Resident R43, who was cognitively intact and had a history of acute on chronic congestive heart failure, hypertensive heart disease, and other related conditions, had an order for weights to be taken three times a week. However, the facility missed several opportunities to record weights over multiple months, and there was no evidence of provider notification regarding these missed weights. The resident reported feeling like she was gaining water weight, and her weight had increased over time, but the scheduled weigh-ins were not consistently performed. The Director of Nursing confirmed the orders for both residents and acknowledged the nursing staff's responsibility to obtain, document, and communicate any concerns regarding scheduled weights. The facility's policy required prompt notification of the resident's attending physician for changes in the resident's condition, but this was not adhered to in these cases, leading to the deficiency.
Failure to Update Care Plans for Residents with Heart Failure
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, R33 and R43, who were reviewed for heart failure. R33 was admitted with diagnoses including chronic diastolic congestive heart failure (CHF), atrial fibrillation, chronic obstructive pulmonary disease (COPD), and diabetes. Despite a cardiology clinic note indicating the need for a PRN diuretic for lung congestion and lower extremity edema, R33's care plan was not updated to include interventions for monitoring these conditions. Additionally, hospital discharge orders for weight monitoring were not transcribed or implemented, and the care plan lacked updates for monitoring weight gain or signs of CHF exacerbation. R43, admitted with acute on chronic congestive heart failure and other cardiac conditions, had a care plan that included monitoring for signs of CHF exacerbation. However, despite an order for weights to be taken three times weekly, the care plan was not updated to reflect this, and weights were only recorded once weekly. This discrepancy was noted in physician notes, which highlighted ongoing concerns about the resident's weight gain due to fluid retention. Interviews with the Director of Nursing (DON) confirmed the expectations for nursing staff to implement interventions and update care plans based on assessments, provider notes, and hospital discharge orders. The DON acknowledged that the care plans for both residents were not updated as required, which is crucial for maintaining resident health and providing clear directives to prevent acute exacerbations of heart failure. A policy was requested during the interview but was not provided.
Failure to Notify Physician of Missed Medication Leads to Critical Low Potassium
Penalty
Summary
The facility failed to notify a resident's physician about a missed administration of medication, which led to a critical low potassium level in the resident. The resident, who had been admitted from the hospital with increased edema and pain, was prescribed Bumex for edema and potassium supplements due to low potassium levels. However, the potassium medication was not available from the pharmacy, resulting in the resident missing ten doses over several days. Despite the critical nature of the resident's low potassium levels, the facility staff did not inform the resident's physician about the missed doses until several days later. Interviews with staff revealed that they were aware of the medication's unavailability and the resident's low potassium levels but failed to contact the physician for further guidance. The facility's policy required prompt notification of the provider in the event of significant medication-related errors, which was not adhered to in this case. The resident's potassium level continued to drop, reaching a critically low level, which necessitated emergency medical services. The facility's failure to communicate the medication error and the resident's declining condition to the physician in a timely manner was a significant oversight, as per the facility's policies on medication errors and changes in resident condition.
Failure to Administer Potassium Timely Leads to Critical Deficiency
Penalty
Summary
The facility failed to ensure that potassium was available and administered timely as prescribed by the physician for a resident, resulting in the resident missing 10 doses of potassium. This led to a critically low potassium level of 2.4 mmol/L, requiring intravenous potassium administration. The resident, who was asymptomatic and stable, had been admitted from the hospital with a history of E. coli pneumonia and septic shock, and was experiencing pain and edema in the lower extremities. The resident's potassium level was initially recorded at 3.8 mmol/L upon admission, but dropped to 2.8 mmol/L, prompting an order for potassium chloride to be administered twice daily. However, the medication was not available from the pharmacy, and despite multiple faxes sent by the facility to the pharmacy, the potassium was not delivered until several days later. During this period, the resident's potassium level further decreased to 2.4 mmol/L, necessitating an emergency room visit for treatment. Interviews with facility staff revealed that there was a breakdown in communication and follow-up procedures, as staff did not adequately follow up with the pharmacy or notify the provider about the unavailability of the medication. The pharmacy also failed to process the order correctly, leading to a delay in medication delivery. The facility's policies on medication administration and error reporting were not adhered to, contributing to the deficiency.
Inadequate Infection Control During Renovation
Penalty
Summary
The facility failed to implement effective infection control measures during a demolition and renovation project, which had the potential to impact all 51 residents. The project was not overseen by a licensed contractor, and the facility did not adhere to CDC guidelines for infection control in long-term care construction. As a result, construction odors and dust traveled into resident areas, and a potential black mold discovery was not properly remediated. The facility did not establish a multidisciplinary team to coordinate the project, nor did it perform an Infection Control Risk Assessment (ICRA) before the project began. The construction area lacked proper barriers to prevent dust and mold spores from spreading, and there was no negative air pressure or air filtration system in place. The facility also failed to relocate immunocompromised residents or monitor their respiratory health during the project. Communication among staff was inadequate, with the Director of Nursing (DON) and Infection Control Preventionist (ICP) not being involved in decision-making or risk mitigation. Volunteers, rather than qualified contractors, managed the project, and there was no evidence of proper mold remediation. The facility's policies on construction and infection control were not followed, and there was a lack of documentation and monitoring of resident health during the construction.
Failure to Address Severe Allergies During Construction
Penalty
Summary
The facility failed to provide necessary care and services to a resident with severe environmental allergies, particularly during a period of construction. The resident, who was cognitively intact and had a history of chronic systolic congestive heart failure and allergic rhinitis, experienced significant discomfort and health issues due to exposure to construction-related odors and dust. Despite being offered a room change and other measures like an N95 mask and supplemental oxygen, the resident declined the room change, believing the odors permeated the entire facility through the ventilation system. The facility's care plan for the resident lacked critical information regarding her severe allergies and the necessary interventions to mitigate risks. The care plan did not include details about the resident's perfume and medication allergies, nor did it provide guidance on how to manage her reactions to allergens. Staff were not adequately informed or trained on the resident's specific needs, leading to repeated exposure to allergens and subsequent health issues for the resident. The resident expressed frustration and fear for her safety, feeling that staff did not take her allergies seriously or understand the severity of her condition. Observations during the survey revealed inadequate barriers to contain construction debris and odors, contributing to the resident's distress. Interviews with staff indicated a lack of consistent communication and documentation regarding the resident's allergies and the necessary precautions. The facility's failure to update the care plan and ensure all staff were aware of the resident's needs resulted in ongoing exposure to allergens, causing the resident to experience respiratory issues and consider relocating due to the facility's inability to provide a safe environment.
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 32 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 Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Melrose | 12.1 mi | ★★★★★ | 14 | 0 |
| Assumption Home | 14.2 mi | ★★★★★ | 0 | 0 |
| Sartell Therapy Suites | 17.5 mi | — | 0 | 0 |
| Sterling Park Health Care Center | 18.3 mi | ★★★★★ | 0 | 0 |
| Country Manor Health & Rehab Ctr | 18.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Benedictine Living Community Mother Of Mercy.
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.