Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 St Benedicts Care Center during CMS and state inspections, most recent first.
A resident with multiple serious medical conditions, who required a full mechanical lift with two-person assistance for transfers, was being moved using an EZ Way Smart Lift when staff failed to follow the manufacturer’s instructions and facility policy requiring a second staff member to double check all sling strap attachments. One NA had already attached the sling to the lift before the second NA arrived, and the second NA did not verify the sling connections before the resident was raised and the wheelchair removed. The resident fell when a shoulder strap detached from the lift, resulting in a significant eyebrow laceration that required ED treatment and multiple sutures. An EZ Way representative, the medical director, and the DON all confirmed that the required final check of all four sling loops/straps was not performed and that the sling was not correctly hooked to the lift.
A resident with benign prostatic hyperplasia and an indwelling Foley catheter was not placed on Enhanced Barrier Precautions (EBP) despite facility policy and CDC guidance requiring EBP for residents with indwelling medical devices. During a transfer between wheelchairs using a full-body mechanical lift, two NAs handled the resident’s catheter bag and performed the high-contact activity without gowns or gloves, and there was no EBP signage or PPE at the room. Both NAs stated that residents with wounds or catheters should be on EBP but relied on door signage to know when to use it. The RN responsible for initiating EBP and posting signage later acknowledged the resident should have been on EBP but had not been placed on it, and the DON confirmed the RN’s responsibility under the facility’s EBP policy.
A resident who relied on staff for all toileting needs experienced significant delays in call light response, leading to incontinence and requiring her adult son to assist with toileting. The resident reported embarrassment and distress due to these events, and call light logs confirmed at least one prolonged response time. The DON acknowledged the importance of timely assistance to maintain dignity, but no policy on dignity was provided.
A resident receiving warfarin for atrial fibrillation, with a history of heart failure and blood clots, did not have anticoagulant use or monitoring for bleeding risks included in their care plan. Interviews with the DON and nurse manager confirmed the omission, despite facility protocols requiring such monitoring.
The facility failed to ensure that four residents were offered or provided the pneumococcal vaccine series as recommended by the CDC. Despite having various medical conditions, these residents' immunization records showed no pneumococcal vaccines were administered, offered, or refused, contrary to MDS records. The DON acknowledged the oversight and noted that a recent audit was delayed, and vaccinations should have been reviewed earlier. The facility's policy did not include the administration of PCV15 and PCV20 vaccines.
A facility failed to document the correct advanced directives for a resident, leading to a discrepancy between the resident's DNR status and the paper chart, which contained another resident's Full code directive. Staff relied on the paper chart for verification, resulting in incorrect information being used. The facility's policy required that advance directives be maintained and easily accessible in the resident's medical record.
A facility failed to follow infection control protocols for a resident on contact precautions. Despite signage requiring gowns and gloves, a housekeeper entered the resident's room wearing only gloves. Interviews with staff confirmed the requirement for gowns and gloves, which was not followed, leading to a deficiency in infection control practices.
The facility failed to accurately post daily staffing hours, affecting all residents and visitors. The staff posting, observed in a public area, showed discrepancies between hours worked and scheduled, and lacked a category for RNs. The DON confirmed the posting did not reflect the actual schedule and incorrectly listed all licensed staff as LPNs. The issue was attributed to a software error since March 2024.
A resident with severe vascular dementia reported a fall and rib pain, leading to an x-ray that revealed fractures. The LPN on duty failed to notify the physician or on-call nurse immediately, as required by facility policy, instead informing the family and placing the report in a non-emergent folder. The oversight was discovered the next morning by an RN, who then notified the physician and DON.
Failure to Verify Sling Attachment During Mechanical Lift Transfer Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow the manufacturer’s instructions and its own policy for safe use of an EZ Way Smart Lift during a full-body mechanical lift transfer. A resident with diagnoses including palliative care, wild-type transthyretin-related amyloidosis, stage IV chronic kidney disease, and rhabdomyolysis was care planned to require a full mechanical lift with assistance of two staff for transfers and was cognitively intact and totally dependent for transfers. On the day of the incident, one nursing assistant had already attached the sling to the lift before a second nursing assistant entered the room to assist. The second nursing assistant did not double check the sling strap attachments, despite acknowledging that policy required a second staff member to verify that all sling straps were correctly and securely attached before lifting. The resident was lifted in the full-body mechanical lift until no longer touching the wheelchair, at which point the wheelchair was pulled away. The resident then fell from the lift when the right shoulder strap came off the lift, landing on the right side and sustaining a laceration above the right eye. The LPN responding to the incident found the resident on the floor on the right side, bleeding from the right eye, and the resident was sent to the ED. ED documentation indicated the resident had a 5.0 cm right eyebrow laceration after a fall from a mechanical lift and required oxycodone, local anesthetic, and 19 sutures, including multiple layers due to the depth of the laceration. The EZ Way representative, the medical director, and the DON each stated that staff did not perform the required final check of all four sling loops/straps per the operator’s manual and facility policy, and that the sling had not been hooked correctly to the lift.
Failure to Implement Enhanced Barrier Precautions for Resident With Foley Catheter
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement Enhanced Barrier Precautions (EBP) in accordance with CDC guidelines and facility policy for a resident with an indwelling urinary catheter. The resident was admitted with benign prostatic hyperplasia with lower urinary tract symptoms and had an indwelling Foley catheter documented on the admission record, care plan, and order summary. During an observation, two nursing assistants entered the resident’s room to transfer him from one wheelchair to another for an appointment. There was no EBP signage or supplies on the resident’s door or in the room, and the nursing assistants did not wear gowns or gloves while performing the transfer, which included handling the resident’s catheter bag when attaching it to the lift sling and then to the new wheelchair. During interviews, both nursing assistants stated that residents with wounds or catheters should be on EBP and acknowledged that the resident had a Foley catheter, but they relied on door signage and supplies to know when to use EBP and were unsure why this resident was not on EBP. A subsequent observation showed that EBP signage and PPE were later placed on the resident’s door. The RN responsible for placing EBP signage and equipment outside resident rooms stated that the resident had a Foley catheter and, after clarification, acknowledged the resident should have been on EBP but was not until a later date. The DON confirmed that the RN was responsible for placing the resident on EBP by following facility policy, which specifies that EBP applies to residents with wounds or indwelling medical devices, including urinary catheters, and that gowns and gloves are to be used for high-contact resident activities such as transfers. The DON was not sure why the resident had not been placed on EBP earlier.
Failure to Provide Timely Toileting Assistance Resulting in Loss of Dignity
Penalty
Summary
A cognitively intact resident who was dependent on staff for all toileting needs experienced delays in staff response to call lights, resulting in episodes of incontinence and a loss of dignity. The resident reported that on multiple occasions, staff failed to respond in a timely manner to requests for toileting assistance, with some wait times exceeding 20 minutes and one instance reportedly lasting over two hours. On one occasion, after staff turned off the call light and stated they would return but did not, the resident's adult son had to assist with toileting, which the resident described as embarrassing and distressing. Call light logs confirmed that while some calls were answered promptly, there was at least one instance where the response time was over 29 minutes. The Director of Nursing acknowledged that all staff are expected to answer call lights and that delays can occur during busy times, but emphasized the importance of timely assistance to maintain resident dignity. The facility was unable to provide a policy regarding dignity when requested.
Failure to Include Anticoagulant Monitoring in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan addressed the management and monitoring of anticoagulant therapy. The resident, who was cognitively intact and had diagnoses including atrial fibrillation, acute embolism and thrombosis of deep veins, and heart failure, was receiving varying doses of warfarin for atrial fibrillation. Despite these conditions and the use of anticoagulant medication, the resident's care plan did not include any mention of anticoagulant use, increased risk for bleeding, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with the nurse manager and the Director of Nursing confirmed that the care plan lacked a focus area related to anticoagulant therapy or instructions for monitoring side effects such as bleeding or bruising. The facility's own anticoagulation protocol required staff to assess for adverse drug reactions and monitor for complications like excessive bruising or bleeding, but these requirements were not reflected in the resident's care plan. Additionally, the facility was unable to provide a care plan policy when requested.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that four out of five residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. The residents involved had various medical conditions, including hypertension, peripheral vascular disease, malnutrition, respiratory failure, heart failure, coronary artery disease, cerebrovascular accident, Parkinson's disease, and dementia. Despite these conditions, the immunization records for these residents indicated that no pneumococcal immunization had been administered, offered, or refused, contradicting the minimum data set (MDS) records that suggested the vaccine had been offered and declined. The Director of Nursing (DON), who also serves as the infection preventionist, acknowledged during interviews that the records for these residents failed to indicate the administration of the PCV20 vaccinations. The DON admitted that a recent audit of all facility residents had not been conducted until a specific date, and the vaccinations should have been reviewed and offered earlier. The facility's policy on pneumococcal vaccination stated that residents would be offered the vaccine according to CDC recommendations, but it failed to include the administration of the PCV15 and PCV20 vaccines.
Failure to Document Correct Advanced Directives
Penalty
Summary
The facility failed to ensure the correct advanced directives were documented and stored in the resident's paper chart for one resident reviewed for advanced directives. The face sheet and current order summary report for the resident indicated a Do Not Resuscitate (DNR) status. However, upon review of the paper chart, an Advanced Directive Consent (ADC) form for a Full code was found, which belonged to another resident, not the resident in question. Staff members, including a registered nurse (RN) and a licensed practical nurse (LPN), were observed verifying the resident's code status by referring to the paper chart, which incorrectly indicated a Full code due to the presence of another resident's ADC form. The unit manager and the director of nursing confirmed the expectation for staff to verify code statuses using the paper chart and, if necessary, the electronic health record. The facility's policy required that advance directives be maintained in the resident's medical record and be readily retrievable by staff.
Failure to Follow Contact Precautions for Resident
Penalty
Summary
The facility failed to adhere to infection control protocols for a resident on contact precautions. On July 29, 2024, a sign was posted on the resident's door indicating the need for contact precautions, including wearing a gown and gloves before entering the room and removing them before exiting. Despite these instructions, on July 31, 2024, a housekeeper was observed in the resident's room wearing only gloves and not a gown while adjusting the resident's blanket and cleaning the room. The housekeeper believed that a gown was not necessary for these tasks, despite the clear signage indicating otherwise. Interviews with the unit manager RN and the DON confirmed that the facility's policy required staff to wear both a gown and gloves when entering the room of a resident on contact precautions, regardless of the task being performed. The resident was on contact precautions due to an unknown rash, and the facility's policy, dated September 2022, mandated that contact precautions be implemented for residents with known or suspected infections that could be transmitted through direct contact. The failure to follow these protocols was acknowledged by the facility's staff.
Inaccurate Daily Staffing Postings
Penalty
Summary
The facility failed to accurately post daily staffing hours, which could potentially affect all residents and visitors. On a specific date, the staff posting was observed in a public area next to a main set of elevators. Upon review, there was a discrepancy between the hours worked and the hours scheduled, and the staff posting did not include a category for registered nursing (RN). The Director of Nursing (DON) confirmed that the daily staff posting did not reflect the actual staff schedule and incorrectly listed all licensed nursing staff as licensed practical nurses (LPN), without differentiating between LPN and RN hours. The posting did not indicate an RN scheduled in the building at any time. During an interview, the DON stated that the daily staff posting was completed by herself or a health information specialist during the week and by another staff member over the weekend. The DON also mentioned that the schedule would be updated and reprinted if a call-in or change occurred. However, the DON acknowledged that the daily staff posting had been incorrect since the facility started using a new software on March 22, 2024, due to an error in the report generated by the software. The facility's policy, dated August 2022, required that the number of licensed nurses and unlicensed nursing personnel responsible for direct care be posted within two hours of the beginning of each shift, including the type and category of nursing staff working.
Failure to Timely Notify Physician of X-ray Results
Penalty
Summary
The facility failed to notify the ordering physician of x-ray results in a timely manner for a resident who had newly identified fractures. The resident, diagnosed with severe vascular dementia with anxiety and mood disturbance, reported a fall and subsequent rib pain. An x-ray was ordered, and results indicating fractures were received by the facility in the evening. However, the Licensed Practical Nurse (LPN) on duty did not notify the physician or the on-call nurse immediately, as required by facility policy. Instead, the LPN informed the resident's family and placed the x-ray report in the physician's folder, which was intended for non-emergent issues. The Registered Nurse (RN) discovered the oversight the following morning and notified the physician and the Director of Nursing (DON). The DON confirmed that the LPN failed to follow protocol by not promptly communicating the x-ray results, which revealed significant injuries. The facility's policy required immediate notification of the physician in cases of serious injury, but this was not adhered to, leading to a delay in the physician being informed of the resident's condition.
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 41 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 Saint Cloud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Of St Cloud | 0.5 mi | ★★★★★ | 0 | 0 |
| Sterling Park Health Care Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Lutheran Home | 4.9 mi | ★★★★★ | 0 | 0 |
| Country Manor Health & Rehab Ctr | 6.1 mi | ★★★★★ | 4 | 0 |
| Sartell Therapy Suites | 8.4 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Benedicts Care Center.
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.