Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benedictine Living Community Of St. Peter during CMS and state inspections, most recent first.
A grievance deficiency occurred when the facility did not provide a confidential way for residents to submit concerns anonymously. Grievance forms were available on the units, but no secure collection box was present, and the SS director and administrator confirmed residents could only give forms to staff or place them under the director’s door. During resident council, multiple residents stated they were unaware of any anonymous grievance process and were unsure how forms should be submitted.
Infection Control Signage and Laundry Handling Failures: The facility did not post entrance signage or provide facemasks and hand sanitizer to support respiratory hygiene, cough etiquette, and hand hygiene. In addition, a laundry assistant handled soiled resident laundry without a gown, allowed laundry to contact her clothing, and later carried clean resident laundry against the same shirt, which the infection preventionist and DON acknowledged as an infection control concern.
A resident with severe cognitive impairment and no documented mood or behavioral issues remained on multiple psychotropic medications, including an antipsychotic, antidepressant, and antianxiety medication, without a documented GDR or clinical justification. Consultant pharmacy repeatedly recommended dose reductions, but the responses were left blank and provider notes did not show a pharmacy request, psychiatry deferral, or rationale to continue the meds. The resident’s PHQ-9 scores were 0, behavior concerns were minimal, and staff interviews confirmed the GDR requests were not clearly addressed in the record.
A resident with dementia and pain-related care needs had an x-ray ordered for right foot pain, but the result was not reviewed or documented in the record, and the resident and family were not notified. The resident later stated she had not heard back about the results and still had ongoing pain, while the NP, LPN, RN, and DON confirmed there was no documentation showing the x-ray report was received, communicated, or acted upon.
A resident with dementia, weakness, unsteadiness, and a walker fell in the hallway when his walker became caught on a vitals machine placed in his usual path, resulting in a femur fracture and hip repair. Although the fall was linked to the environmental hazard and the machine was supposed to be kept out of the hallway, later observation showed the machine again in the direct path to the resident's room, and staff interviews showed inconsistent awareness and no clear sign-off that the new fall intervention had been communicated.
Nursing staffing information was not clearly posted to show RN hours for residents, staff, and visitors. The daily staffing sheet near the administrative offices listed RN in several places, but each time RN was shown alone the count was zero, so it was not clear whether an RN had been on duty. The DON stated there was a licensed nurse on duty 24/7 and at least one RN on duty for 8 consecutive hours each day, but the staffing coordinator and health information coordinator agreed the form did not clearly reflect RN coverage, and prior staffing postings also failed to identify RN hours or staffing adjustments.
The facility failed to document indications or diagnoses for medications prescribed to five residents, leading to a deficiency in ensuring drug regimens were free from unnecessary drugs. Residents with cognitive impairments and various medical conditions were prescribed multiple medications without documented purposes, despite being at risk for adverse reactions. The DON and consulting pharmacist acknowledged the lack of documentation, which was contrary to the facility's medication administration policy.
A resident with multiple health conditions, including vascular dementia, was found with Systane eye drops at their bedside without an assessment or physician's order for self-administration. Nursing staff confirmed the absence of necessary documentation and stated that the medication should have been stored in the medication cart, as per facility policy.
A resident with a history of dizziness, anemia, and diabetes was not provided with necessary vision services, as their eyeglasses required adjustment. Despite the resident's repeated requests and staff awareness, no timely action was taken to coordinate an appointment for the adjustment. The facility's policy on vision needs was not provided.
A resident with dementia and hypertension was administered a crushed metoprolol succinate extended release tablet without an order to do so, leading to a significant medication error. The medication aide and nursing staff confirmed the error, acknowledging that the extended release tablet should not have been crushed, as it disrupts the medication's intended use.
An LPN failed to perform appropriate hand hygiene during medication administration for two residents, one with impaired cognition and another with fractures. The LPN did not sanitize hands after glove removal or between resident interactions, contrary to facility policies. The nurse manager and infection preventionist confirmed the expectation for hand hygiene before and after resident contact.
The facility failed to document indications for psychotropic medications for two residents, leading to a deficiency. One resident with impaired cognition was prescribed buspirone and quetiapine, but only quetiapine had a specified diagnosis. Another resident with dementia and Parkinson's disease was prescribed sertraline without a documented indication. The Director of Nursing and consulting pharmacist acknowledged the lack of documentation, which was against the facility's medication administration policy.
Grievance Process Lacked Anonymous Submission Method
Penalty
Summary
The facility failed to ensure a process for residents and resident representatives to file grievances anonymously. During observation and interview, grievance forms were seen on each unit, but no confidential collection box was present. The social services director confirmed that grievance forms were available in designated areas and could be given to staff or placed under the director’s door, but there was no secure grievance box and no identified place for anonymous submission. The administrator also stated residents could complete concern forms on the units and give them to any staff member, then confirmed after touring the facility that no confidential receptacle was available, despite expecting one to be present. During the resident council meeting, residents stated they were not aware of any method to submit concerns anonymously. Residents reported they would talk to someone if they wanted to file a grievance, but none were aware of a process for anonymous submission and were unsure whether forms existed or how they should be turned in. The record identified R22 as cognitively intact, R23 as moderately cognitively impaired, and R35, R45, R46, and R63 as cognitively intact on their most recent MDS assessments.
Infection Control Signage and Laundry Handling Failures
Penalty
Summary
The facility failed to follow CDC infection prevention guidance by not posting signage at the main entrance to alert visitors and staff about respiratory hygiene, staying home when ill, hand hygiene, and cough etiquette. During observation on 1/12/26 at 9:45 a.m., no signs were posted at the entrance doors, and no facemasks or hand sanitizer were available at the main entrance. Review of CDC guidance on 1/13/26 indicated that healthcare facilities should post visual alerts at entrances and provide materials such as facemasks and alcohol-based hand sanitizer to support respiratory hygiene and cough etiquette. The facility also failed to follow infection control practices during resident laundry handling. On 1/13/26 at 10:39 a.m., the laundry assistant placed soiled resident laundry into the washing machine without wearing a gown, and resident laundry contacted the assistant’s clothing. The laundry assistant stated she washed all resident personal laundry, sometimes wore a gown, but did not have one available that day because her gown was being washed and there were no disposable gowns in the laundry room. Later that day at 2:11 p.m., the same laundry assistant was observed carrying clean resident laundry to a resident’s room while holding it against the shirt worn during soiled laundry handling. The infection preventionist stated the facility should have signs, masks, and hand sanitizer at the entrance and acknowledged that handling soiled laundry without a gown and then handling clean laundry could spread infection. The DON stated she was not aware the laundry assistant had not been wearing a gown and expected a gown to be worn for infection control purposes.
Failure to Document GDR or Clinical Justification for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) or a documented clinical justification for continued use of psychotropic medications for one resident who was receiving aripiprazole, desvenlafaxine succinate, and alprazolam. The resident’s annual MDS indicated severe cognitive impairment, no mood or behavioral issues, and dependence on staff for most activities of daily living and transfers. The care plan identified psychotropic medication use and noted that GDRs were to be attempted as indicated. The resident’s record showed repeated consultant pharmacist recommendations to reduce psychotropic medications, including aripiprazole, desvenlafaxine, and alprazolam, with requests to verify the resident was on the lowest possible dose. The responses to those recommendations were left blank, and progress notes from the nurse practitioners did not include a pharmacy request for GDR, a deferral to psychiatry, or a rationale to continue the medications. The record also showed the resident’s PHQ-9 scores were 0, indicating no depression, and the last documented behavioral issue was an isolated episode in which the resident was upset with a nursing assistant. Additional documentation showed the resident’s AIMS score was 4 and remained unchanged, and later notes described the resident as intermittently dozing off, with no mood concerns reported. During observation and interview, the resident was sitting in a chair, answered yes and no questions, and denied side effects, anxiety, or depression. Staff interviews indicated requests were often sent to psychiatry without response, but the medical record lacked evidence that the provider saw the GDR requests or documented a clinical reason for continuing the psychotropic medications.
Failure to Follow Up on X-Ray Results and Notify Resident, Family, and Provider
Penalty
Summary
The facility failed to ensure follow-up of an ordered x-ray, provider review of the results, and notification to the resident and/or family for a resident with moderately impaired cognition who required assistance with transfers, dressing, and toileting and had diagnoses including non-Alzheimer's dementia and depression. The resident's care plan addressed pain/discomfort related to osteoarthritis and directed staff to monitor for nonverbal indicators of discomfort. An x-ray of the right ankle and right foot was ordered for right foot pain, and the x-ray result later showed no acute bone abnormality. However, the resident stated she had not heard back about the results and continued to report right foot pain and uncertainty about walking ability due to the pain. Interviews with the NP, LPN, RN/nurse manager, and DON showed the facility had no documentation that the x-ray results were received, reviewed, or communicated to the provider, resident, or family. The NP confirmed she had not been contacted about the results. The LPN and RN stated they could not find documentation showing receipt of the report or notification, and the RN stated the results were only located after calling the x-ray company. The RN and LPN both stated they expected a progress note documenting review and notification, and the DON stated nursing staff were responsible for reviewing faxed x-ray reports and notifying the provider, resident, and family, with documentation reflecting that process. The facility policy on change in condition required documentation of symptoms, assessment, observations, resident or representative, and medical provider notification.
Failure to Follow Fall Intervention After Environmental Hazard-Related Fall
Penalty
Summary
The facility failed to ensure a new fall intervention was followed for a resident with a history of falls and major injury. The resident had diagnoses including femur fracture, dementia, muscle weakness, and unsteadiness on feet, and the MDS indicated moderately impaired cognition and use of a walker. After the resident fell in the hallway, he was found on his left side after his walker became caught on a vitals machine that had been placed against the wall in his usual walking path. He reported he had been on the way to the bathroom and got caught on something, and he was transferred to the emergency department with left hip and upper leg pain and a left femur fracture, later returning from the hospital after left hip repair. The fall was documented as related to an environmental hazard combined with the resident's cognitive impairment, and the event note stated the vitals machine was to be removed from the hallway and kept in an alternate location. However, during later observation, a vitals machine on wheels was again plugged in along the wall in the hallway directly outside the resident's room and in the direct path to his room. Staff interviews showed inconsistent awareness of the intervention: one RN was unaware the machine was not supposed to be there, nursing assistants stated communication was poor or that they did not know where to find new fall interventions, and the case manager could not find a sign-off sheet showing staff had been informed of the new intervention. The DON stated she expected fall interventions to be followed and staff to be made aware of new fall interventions to prevent additional falls.
Nursing Staffing Posting Did Not Clearly Show RN Hours
Penalty
Summary
The facility failed to ensure required nursing staffing information, specifically RN hours, were posted for residents, staff, and visitors. During observation, the daily staffing posting located near the entrance to the administrative offices was reviewed and it was not clear from the information posted whether an RN had been on duty. The posting listed multiple nursing positions for the day, evening, and night shifts, but each time RN was listed by itself, the number of staff was shown as zero. During interview, the DON stated there was a licensed nurse on duty 24/7 and at least one RN on duty for eight consecutive hours each day, but the posting did not clearly reflect that information. During interview, the staffing coordinator and health information coordinator reviewed the posting with the DON and agreed that one could not tell if an RN had been scheduled to work that day. The health information coordinator stated she was responsible for the form and would make the necessary changes to reflect individual RN hours, and the staffing coordinator admitted she did not adjust the form for staff absences due to call outs or illness. Review of staffing posting forms for prior months and January 2026 showed an RN was not identified as working and staffing adjustments were not noted, while nursing schedules for October 2025 through January 2026 indicated at least one RN had been scheduled to work each day.
Failure to Document Medication Indications for Residents
Penalty
Summary
The facility failed to identify diagnoses or indications for the use of medications for five residents, leading to a deficiency in ensuring that each resident's drug regimen was free from unnecessary drugs. Resident R37, with moderately impaired cognition and various behavioral issues, was prescribed multiple medications, including psychotropic drugs, without documented indications or diagnoses in the Physician Order Report or Medication Administration Record (MAR). Similarly, Resident R48, who had severe cognitive impairment and multiple diagnoses such as renal failure and diabetes, was also prescribed numerous medications without documented indications or diagnoses. Resident R59, who had no cognitive impairment but required assistance with daily activities and had diagnoses of dementia and Parkinson's disease, was at risk for adverse reactions due to high-risk medications that lacked documented indications or diagnoses. Resident R67, with moderately impaired cognition and diagnoses including hypertension and renal failure, was also prescribed medications without documented indications or diagnoses, despite being at risk for adverse reactions from psychotropic medications. Lastly, Resident R42, with severe cognitive impairment and Alzheimer's disease, was prescribed warfarin without a documented diagnosis or indication for use. The Director of Nursing (DON) confirmed that medications were expected to have indications or diagnoses on the MAR and provider orders to ensure staff knew the purpose of each medication. The consulting pharmacist stated that the provider was responsible for attaching a diagnosis to the medication order and that the facility should contact the provider if a medication order lacked a diagnosis. The facility's policy on administering medications emphasized the importance of ensuring safe administration with the indication for each medication order.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R65, was appropriately assessed and deemed suitable to self-administer medications. R65, who had diagnoses including cerebral infarction, muscle weakness, chronic kidney disease, and vascular dementia, was observed to have a bottle of Systane eye drops on the bedside table within reach. Despite the presence of these medications, there was no documented assessment or physician's order authorizing R65 to self-administer medications. Interviews with nursing staff, including a registered nurse and the nurse manager, confirmed that R65 did not have an order for self-administration and that the eye drops should have been stored in the medication cart. The director of nursing also stated that an assessment should have been completed to ensure R65's safety in having medications at the bedside. The facility's policy on self-administration of medications requires an interdisciplinary team assessment to determine if it is clinically appropriate and safe for a resident to self-administer medications. This assessment should be documented in the electronic medical record, which was not done in R65's case, leading to the deficiency.
Failure to Address Resident's Vision Needs
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain optimal visual abilities for a resident, identified as R2, who was reviewed for vision care. R2's medical history includes conditions such as dizziness, anemia, and type 2 diabetes. According to R2's admission minimum data set, R2 had adequate vision with the use of corrective lenses. However, observations on two consecutive days revealed that R2 was not wearing eyeglasses. During interviews, R2 expressed that the eyeglasses needed adjustment as they kept sliding down the nose, and this issue had been reported to the staff at the end of September. Despite R2's repeated requests for eyeglass adjustments, the facility staff did not take timely action. Nursing Assistant A confirmed that R2 had requested the adjustment, and the concern was communicated to the unit manager. LPN-B also acknowledged R2's request and mentioned that the adjustment needed to be done outside the facility, but no further action was taken. RN-A admitted to being aware of the issue but forgot to coordinate the necessary appointment and transportation for the adjustment. The facility's policy on vision or eyeglass needs was requested but not provided, indicating a lack of documented procedures to address such issues.
Significant Medication Error Due to Improper Crushing of Extended Release Tablet
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, identified as R15, had a diagnosis of unspecified dementia, muscle weakness, anxiety disorder, and essential primary hypertension. The resident required substantial assistance for daily activities and had severely impaired cognition. According to the physician's orders, R15 was prescribed metoprolol succinate extended release 25 mg tablet daily for high blood pressure. However, during an observation, a trained medication aide (TMA-A) was seen crushing the metoprolol succinate extended release tablet along with other medications for ease of swallowing, despite there being no order to crush this medication. Interviews with TMA-A, RN-A, the director of nursing, and a consulting pharmacist confirmed that the metoprolol succinate extended release tablet should not have been crushed, as it interferes with the medication's intended release mechanism. The facility's policy on administering medications requires that medications be administered in accordance with the orders, which was not followed in this case. The incident highlights a significant medication error due to the improper handling of the extended release medication without appropriate orders.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during medication administration for two residents. One resident, with moderately impaired cognition, required supervision with personal hygiene. During medication administration, an LPN applied eye drops, lidocaine, and administered a pill with applesauce without performing hand hygiene after removing gloves. The LPN then handled medication storage without sanitizing hands, and reused the applesauce for future medication administration. Another resident, admitted with hip and shoulder fractures, received medication from the same LPN who failed to perform hand hygiene before entering the resident's room. The LPN handled the resident's water mug with bare hands, refilled it, and returned it without sanitizing hands during the entire process. The LPN confirmed the lack of hand hygiene during the medication pass, stating it was not her usual practice to perform hand hygiene when gloves were used. The nurse manager and infection preventionist nurse confirmed that staff were expected to complete hand hygiene after glove removal, before entering or exiting a resident's room, and before the next medication administration. The facility's hand hygiene policy emphasized the importance of hand hygiene in preventing the spread of germs, and the medication administration policy required adherence to infection control procedures.
Failure to Document Indications for Psychotropic Medications
Penalty
Summary
The facility failed to identify diagnoses or indications for the use of psychotropic medications for two out of five residents reviewed for unnecessary medications. Resident R37, who had moderately impaired cognition and required substantial assistance with personal hygiene, was receiving psychotropic medications including buspirone and quetiapine. However, the Physician Order Report and Medication Administration Record (MAR) lacked indications for the use of buspirone, and only quetiapine had a specified diagnosis of delusional disorder. Similarly, Resident R59, who had no cognitive impairment but required assistance with daily activities and had diagnoses of dementia and Parkinson's disease, was prescribed sertraline without an indication for use or diagnosis documented in the MAR. Resident R67, with moderately impaired cognition and diagnoses of hypertension, renal failure, and dementia, was also receiving psychotropic medications such as buspirone and Lexapro without documented indications for use. The Director of Nursing acknowledged that medications were expected to have an indication or diagnosis on the MAR and provider orders. The consulting pharmacist stated that it was the provider's responsibility to attach a diagnosis to the medication order and that the facility should contact the provider if a medication order lacked a diagnosis. The facility's policy on administering medications emphasized the importance of ensuring safe administration with the indication for each medication order.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near St Peter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Le Sueur | 7.7 mi | ★★★★★ | 12 | 0 |
| Central Health Care Center | 12.6 mi | ★★★★★ | 3 | 0 |
| Oaklawn Care & Rehabilitation Center | 13.1 mi | ★★★★★ | 2 | 0 |
| Pathstone Living | 13.3 mi | ★★★★★ | 25 | 0 |
| Hillcrest Care & Rehabilitation Center | 14.2 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.