Average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 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.
Undated and Open Frozen Foods in Second-Floor Kitchenettes: A dietary assistant and surveyor found multiple frozen food items in two second-floor kitchenettes that were undated, and several bags were left open. Items included hamburger patties, omelets, French toast, waffles, pancakes, macaroni and cheese, corn dogs, and hot dogs. The DM stated foods stored longer than one day should be dated, and the facility policy required frozen foods to be covered, labeled, and dated.
Resident Bill of Rights Not Updated or Reviewed: The facility failed to ensure the most current RBOR was provided to residents and displayed for residents, visitors, and staff. A resident said the RBOR was posted but did not recall anyone reviewing it at admission. Surveyors observed an outdated RBOR posted on the first floor, while the admission packet and a wall-hanger copy contained a later revised version. The DON and SSD stated they were not aware the RBOR had been updated, and the SSD did not personally review it with residents at admission.
A resident admitted for rehab after a short hospital stay, with diagnoses including anemia, CAD, DM, and long-term anticoagulant use, left the facility AMA. The record showed the daughter was present, the PCP was updated, and a MAARC report was filed, but the discharge tracking log did not show that the Ombudsman was notified. The Admin confirmed the facility did not routinely report AMA discharges to the Ombudsman.
Care Plan Lacked Dialysis-Specific Information: A resident with acute kidney failure and renal failure was receiving hemodialysis 3 days per week, but the care plan did not include a dialysis-specific focus, goal, or interventions. RN and DON both confirmed the plan lacked basic details such as the nephrologist, dialysis location, access site care and monitoring, and the dialysis schedule.
Failure to Provide Shaving Assistance: A resident who was severely cognitively impaired and dependent on staff for ADLs was supposed to be shaved every morning and preferred to be clean shaven, but was repeatedly observed with whiskers on his face and neck over several days. The NA said the resident needed total assistance with shaving and was not shaved one morning because the electric razor was broken, while the RN stated staff should use the care guide/Kardex and report equipment issues when discovered; the DON confirmed the resident’s grooming preference and that staff should document the care actually provided.
Failure to arrange dental care for a resident with no upper teeth and only a few lower teeth. The resident said they wanted dentures and had difficulty eating, but the dental assessment and referral noted a need to question upper dentures and a lower partial, and the EMR showed no follow-up. An LPN was unaware of the resident’s denture request, and an RN said dental care was not typically addressed quarterly during care conferences.
An LPN used a shared glucometer for two residents and returned it to the med cart without disinfecting it between uses, despite the meter instructions and facility policy requiring cleaning and disinfection between residents with an EPA-registered wipe. The infection preventionist and DON also confirmed the IPCP had not been reviewed annually, even though the policy required annual review by the infection control committee and key staff.
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.
Undated and Open Frozen Foods in Second-Floor Kitchenettes
Penalty
Summary
The facility failed to ensure refrigerated and frozen food items in second-floor kitchenettes were properly labeled, dated, and closed after packaging was opened. During observation and interview on 08/03/2026 at 10:28 a.m., a dietary assistant and surveyor reviewed the Parker's Lane kitchenette refrigerator/freezer and found one hamburger patty in an open plastic bag, one omelet in an undated plastic bag, one French toast in an undated plastic bag, five waffles in an open undated plastic bag, multiple pancakes in plastic bags with one bag left open and undated, and two macaroni and cheese items wrapped in plastic and undated. During a separate observation and interview on 08/03/2026 at 10:38 a.m., a dietary assistant and surveyor reviewed the Therapy Suite kitchenette refrigerator/freezer and found multiple corn dogs, hamburger patties, pancakes, omelets, hot dogs, and waffles in plastic bags that were undated, with one waffle bag left open. The dietary assistant stated foods in refrigerators and freezers were supposed to be dated and removed the waffles from the open bag, taped the bag closed, and returned it to the freezer. On 8/4/26, the dietary manager stated all food items should be dated if stored longer than one day, that dating was important for first-in, first-out use, and that open bags could allow cross contamination. The facility policy stated frozen foods should be covered, labeled, and dated, and that foods should be checked to ensure they were consumed by their safe use by dates or discarded.
Resident Bill of Rights Not Updated or Reviewed
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Bill of Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. During interview, a resident stated the RBOR was posted on the first floor but did not recall anyone sitting down and going over the bill of rights. Observation showed the RBOR displayed across from the kitchen door on the first floor was dated 7/1/07. Review of the admission packet showed an RBOR revised 11/28/16 and modified 2/1/17, and another RBOR in a clear plastic wall hanger was also modified 2/1/17. The DON stated the social service director worked with marketing and ordered items needed for the admission packets, and that they were not aware the RBOR had been updated. The SSD stated they did not personally go over the RBOR at admission and were not aware who was responsible for updating the posters or whether residents had been updated regarding the revised RBOR. A policy regarding RBOR was requested but not provided.
Failure to Notify Ombudsman of Resident AMA Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a resident transfer/discharge for 1 of 2 residents reviewed for Ombudsman notification. The resident was admitted for rehabilitation after a short hospital stay and had diagnoses including anemia, coronary artery disease, diabetes, and long-term use of anti-coagulants. The medical record showed an admission MDS dated [DATE], an Entry Tracking record dated 6/22/2026, and a PPS-Discharge Assessment marked return not anticipated. Progress notes documented that the resident left the facility against medical advice at 2:00 p.m., with the daughter present and the primary care provider updated, and that a MAARC report was filed later that day. Review of the May and June discharge tracking log did not identify that the Ombudsman had been notified of the resident's transfer/discharge, and the Administrator confirmed during interview that the facility did not routinely report residents who left AMA to the Office of the Ombudsman and that the Ombudsman was not notified when this resident left.
Care Plan Lacked Dialysis-Specific Information
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with kidney failure who was receiving hemodialysis. R1's admission MDS dated [DATE] indicated she was cognitively intact, required minimal to moderate assistance with activities of daily living, and had diagnoses of acute kidney failure and renal failure. R1's EMAR showed an order for dialysis every Tuesday, Thursday, and Saturday, but her care plan did not include a focus, goal, or intervention specific to dialysis. During interview, RN-A confirmed R1 received dialysis 3 days per week and stated the care plan did not contain information about R1's nephrologist, where she received dialysis treatments, or how to monitor or care for the dialysis site. RN-A stated she would expect basic information related to dialysis. The DON also confirmed the care plan lacked a focus, goal, and intervention for R1's dialysis treatment and stated she expected care plans for residents receiving dialysis to include information such as access site care and monitoring, nutritional guidelines or restrictions, and the dialysis schedule.
Failure to Provide Ordered Shaving Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for a resident who was dependent on staff for care. The resident’s quarterly MDS indicated severe cognitive impairment and dependence on staff for ADLs, and diagnoses included paraplegia, dementia, anxiety, major depression, and multiple sclerosis. The care plan identified a need for assistance with personal hygiene and noted the resident preferred to be clean shaven. During observations, the resident’s face and neck were repeatedly noted to have black and gray whiskers, including on multiple days and at different times. When asked, the resident indicated that the whiskers bothered him and that he preferred to be shaved every day. A NA stated the resident required total assistance with shaving, usually did not refuse, and preferred to be shaved, but was not shaved one morning because the electric razor was broken. An LPN stated she had just learned that day the razor was broken, and an RN stated staff used care guides and the Kardex to identify care needs, that the resident was to be shaved every morning, and that staff should report equipment issues when discovered. The RN also stated documentation showing the resident had been shaved on one date did not appear consistent with observations and would be investigated as possible inaccurate documentation. The DON confirmed the resident preferred to be clean shaven and that staff should document the care actually provided.
Failure to Arrange Dental Care for Resident Needing Dentures
Penalty
Summary
The facility failed to provide arrangements for dental care for one resident who had moderate cognitive impairment and required staff assistance with ADLs. The resident’s care plan noted a self-care deficit related to impaired mobility and stated the resident was usually independent with oral care but needed assistance at times. The resident’s order summary showed a renal diet with level 7 regular texture. During interview, the resident stated they had no upper teeth and only a couple of lower teeth, had been wanting dentures, had not gotten any, and that eating was difficult at times. The resident’s oral/dental assessment indicated no upper teeth or dentures, only two lower teeth, and no dentures. The dental care referral recommendations called for a routine dental referral and noted non-urgent dental care needs, with a question to nursing staff about upper dentures and a lower partial. Review of the EMR did not identify follow-up on the question of upper dentures and lower partial dentures. An LPN stated they were not aware the resident wanted dentures, and an RN stated the resident had been screened by the facility, had previously been seen by an outside dental office but not since 2004, and became tearful when asked if they wanted to be seen for dentures. The RN also stated dental care was not typically addressed quarterly during care conferences.
Failure to Disinfect Shared Glucometer and Review IPCP Annually
Penalty
Summary
The facility failed to disinfect a common-use blood glucometer after use for two residents who received blood glucose testing on the transitional care unit. During observation, an LPN used the glucometer for one resident, returned it to a basket on the medication cart without sanitizing it, then later used the same glucometer for another resident and again returned it without sanitizing it. The LPN confirmed she had not sanitized the glucometer after either use and stated she should have used Super Sani-Cloths stored on the medication cart. The glucometer involved was an Assure Platinum glucose monitor, and the manufacturer’s instructions indicated the meter should be cleaned and disinfected between patient uses with an EPA-registered disinfectant or germicide wipe, following the product label instructions. The Super Sani-Cloth label stated that surfaces must be thoroughly cleaned before disinfection, and that the wipe must remain wet for two minutes. The facility’s policy also required reusable resident-care equipment, including glucometers, to be cleaned and disinfected between residents according to manufacturer instructions and current infection control standards. The facility also failed to review its Infection Prevention and Control Program at least annually. The infection preventionist and DON both confirmed the IPCP had not been reviewed annually, and the policy itself showed a last review date of 12/23. The policy stated the infection prevention and control committee, medical director, DON, and other key staff were responsible for reviewing infection control policies at least annually.
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.
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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.
Illustrative
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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 | ★★★★★ | 2 | 0 |
| Sterling Park Health Care Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Lutheran Home | 4.9 mi | ★★★★★ | 12 | 0 |
| Country Manor Healthcare And Rehab Center | 6.1 mi | ★★★★★ | 4 | 0 |
| Sartell Therapy Suites | 8.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.