Benedictine Health Center Of Minneapolis
618 East 17th Street, Minneapolis, MN 55404 · Non profit - Corporation · 90 certified beds · (612) 879-2811 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $84,774 in federal fines (most recent 2024-05-23)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.9% | 18.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.6% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.9% | 1.9% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.9% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.7% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.2% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.5% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.9% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.1% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.6% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.6% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 85.3 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.37 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.47 hrs/resident/day on weekends vs 5.19 on weekdays — 14% thinner on weekends. RN hours go from 2.51 to 2.03 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-06-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess and notify provider for change in condition for 1 of 1 resident (R1) reviewed. This resulted in an immediate jeopardy (IJ) situation for R1 when his heart rate (HR) was identified to be 156 bpm (beats per minute), was later found unresponsive with no pulse, CPR (cardiac pulmonary resuscitation) was performed, and he subsequently died at the facility. The immediate jeopardy began on [DATE], when at 1:30 a.m. R1's HR was 156 bpm, and no action taken by registered nurse (RN)-A. Then at 3:40 a.m. R1 was found unresponsive with no pulse, CPR was performed, paramedics arrived at 4:20 a.m., and took over CPR until R1 was pronounced dead at 4:47 a.m. at the facility. The director of nursing (DON) and administrator were notified of the IJ on [DATE], at 4:20 p.m. The IJ was removed on [DATE], following verification of an acceptable removal plan however, noncompliance remained at the lower scope and severity level D, which indicated no actual harm with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-05-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess pressure ulcers and provide necessary treatment and services to prevent and/or mitigate the risk of new ulcer development or deterioration resulting in actual harm with the development of a new pressure injury for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include: Definitions of pressure ulcer types Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis (middle layer of skin), presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Fat is not visible and deeper tissues are not visible. Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (non-viable usually moist tissue than can be soft and stringy in texture) and/or eschar (dead or devitalized tissue that is usually black…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-03 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly manage a potential scabies outbreak in January 2026, resulting in additional rashes requiring scabies treatment for 2 of 2 residents (R73, R15) reviewed who were prescribed an antiparasitic oral medication. Further, upon discovery of R15 and R73's rashes, the facility failed to take appropriate steps to prevent the spread of possible scabies. This had the ability to affect all 85 residents residing in the care facility. In addition, the facility failed to ensure transmission-based precautions were followed, to include enhanced barrier precautions (EBP) and contact precautions for 2 of 4 residents (R24, R45) observed for proper infection control practices. Findings include: During record review it was discovered that 14 residents on the fourth floor and 2 residents on the second floor had a diagnosis of scabies in their chart dated 1/29/26. R73's annual Minimum Data Set, dated [DATE], indicated R73 was admitted to the care facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-03 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 7 out of 24 residents' (R63, R24, R5, R45, R47, R65, R20) fans were kept clean to provide a safe environment for residents with tracheostomies and/or ventilators.Findings include: R63R63's annual Minimum Data Set (MDS) dated [DATE], indicated R63 was unable to speak, had moderately impaired decision making, and depended on staff members for all activities of daily living (ADLs). MDS indicated diagnoses of cardiorespiratory debility, tracheostomy, had a ventilator, and received oxygen and had a tube feeding. During observation on 3/30/26 at 5:35 p.m., R63 was sleeping in bed with her mouth open. A fan mounted on a wall was blowing air and there was dust accumulated on the grid. The fan was stopped, and dust was present on the fan blades. R63 woke during the visit but she was unable to answer questions. R24R24's quarterly MDS dated [DATE], indicated diagnosis of cardiorespiratory debility, unable to talk, had a tracheostomy, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a significant medication error was reported to the State Agency (SA) within 24 hours for 1 of 1 resident (R15) reviewed who received 1/10th of the prescribed dose of seizure prevention medication twice daily for 24 of days.Findings include:R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had severe cognitive impairment, depended on staff for all activities of daily living, and had a diagnosis of hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side. Other diagnoses included hypertension, diabetes, non-Alzheimer's dementia, seizures, and depression.R15's progress notes included:- 10/20/25 note at 4:16 p.m., indicated at 1:00 p.m., a nursing assistant (NA) reported to the nurse on duty R15 was shaking. Nurse indicated R15 was alert, and his right upper and lower extremities were shaking. Vs were obtained. R15's whole body started to shake, 911 was called, and R15 was taken to a local…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-03 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide a bed hold notice for 1 of 1 residents (R12) reviewed for hospitalization.Findings include:R12's quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated R12 had moderately impaired cognition with no hallucinations, delusions or behaviors.During an interview and observation on 3/30/26 at 12:49 p.m., R12 was observed lying in bed. R12 responded to questions with yes or no answers.R12's face sheet, dated 4/2/26, indicated R12 had an identified emergency contact and who would also receive statements.R12's census log, printed 4/2/26, indicated R12 was on hospital leave from 2/22/26 and returned on 2/27/26.R12's progress notes, dated 2/15/26 to 2/28/26, were reviewed and identified the following:-2/22/26 at 11:22 p.m.: resident was sent to the hospital for not responding well. Supervisor, resident's spouse, and on-call provider was notified.-2/23/26 at 2:42 a.m.: facility called to follow up with the hospital who continued to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-03 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident (R88) reviewed for a closed record.Findings include:R88 was admitted to the facility on [DATE] with a diagnosis of aftercare following left knee joint replacement. During R88's stay at the facility, she received therapy services and was discharged from the facility to her home.R88's discharge MDS dated [DATE] indicated, R88 was discharged to a short-term general hospital.R88's electronic medical record (EMR) included a progress note dated 2/9/26 at 3:33 p.m. The progress note indicated R88 was discharged at 11:00 a.m. to her home with her sister. R88's sister provided transportation. Note identified a local home health agency would provide home services. Medication prescriptions were faxed to a local pharmacy, and R88 was discharged with medications as ordered. R88's Discharge Plan of Care indicated R88 returned home on 2/9/26.During interview on 4/2/26 at 9:29 a.m., corporate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who were on transmission-based precautions for potential scabies had a documented diagnosis and care plan to ensure staff and any potential future care facilities were aware to help prevent the spread of scabies for 2 of 2 residents (R15 and R73) reviewed who were currently being treated for scabies. In addition, the facility failed to assure a skin care plan was updated to accurately reflect the skin problems for 1 of 1 resident (R24) reviewed for pressure areas.Findings include:R73's annual Minimum Data Set, dated [DATE], indicated R73 was admitted to the care facility on 1/28/22, and dependent on staff for most activities of daily living (ADLs).R73's orders dated 3/28/26, included an order for 2 doses of ivermectin (an antiparasitic medication used in two doses to treat scabies, among other parasitic infections) 15 milligrams (mg) to be given on 3/28/26 and 4/4/26 for dermatitis.R73's care plan, printed 4/1/26, lacked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to monitor for signs and symptoms of bleeding and failed to follow up with provider to reinstate an anticoagulant medication for 1 of 1 resident (R31) reviewed for change in condition. In addition, the facility failed to obtain laboratory results and update the primary provider in a timely manner to initiate treatment for a urinary infection for 1 of 1 resident (R31) reviewed for urinary infection.Findings include:F31's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R31 was comatose, depended on staff members for activities of daily living, and received food and medications through a tube feeding. MDS indicated R31 received oxygen, had a tracheostomy, received oral suctioning, and had a gastrostomy tube. MDS indicated diagnoses of stroke, atrial fibrillation, heart failure, hypertension, nontraumatic intracerebral hemorrhage, acute and chronic respiratory failure, persistent vegetative state, autonomic dysreflexia and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-03 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to monitor for orthostasis, a common side effect of antipsychotic medication, for 2 of 5 (R2 and R79) residents reviewed for unnecessary medications who also had a history of falls. Findings include:A National Library of Medicine (NIH) Management of Commons Adverse Effects of Antipsychotic Medication article, dated 9/2018, identified the elderly were at risk of adverse effects (i.e., falls) of antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension . [which can] lead to dizziness, syncope, falls . it should be evaluated by both history and measurement . Risk factors include systemic diseases causing autonomic instability (e.g., diabetes, alcohol dependence, Parkinson's disease), dehydration, drug-drug interactions, and age.R79R79's annual Minimum Data Set (MDS), dated [DATE], indicated R79 was cognitively intact and independent with most activities of daily living (ADLs). The MDS further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-16 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure resident identifiable personal health information (PHI) was kept secured and out of public view. This had potential to affect all 73 residents of the second, third and fourth floors whose personal information was listed on exposed care sheets. Findings include: Document titled 3rd Floor Nursing Care Work Sheet downloaded 1/14/25, indicated, Carry this care worksheet with you during your shift; do not leave out for others to see (HIPAA/PHI) [Health Insurance Portability and Accountability Act - federal standards to protect PHI - Personal Health Information]. During observation on 1/15/25 at 8:37 a.m., on the third-floor transitional care unit (TCU), an alcove in the middle of the hallway across from room [ROOM NUMBER] contained two large plastic rolling containers with lids, a linen cart that was covered, and a tall office type chair. On top of the covered linen cart was an unattended, 3rd Floor Nursing Care Work Sheet containing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the resident and/or resident representative participated in care conferences for the planning process and development of interventions for 1 of 1 residents (R36) reviewed for participation of care planning. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2023, the RAI is used to, assist staff with evaluating goal achievement and revising care plans accordingly by enabling the nurse home to track changes in the resident's status. The RAI, establishes a course of action with input from the resident (resident's family and/or guardian or other legally authorized representative), resident's physician and interdisciplinary team that moves a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise. The Assessment Reference Date (ARD) refers to the specific endpoint for the observation period in the MDS assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2025-01-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to revise and update a comprehensive care plan for 1 of 1 resident (R23) who had a foley catheter, psychology provider anxiety interventions, and refusals of care not identified in the care plan. Findings include: R23's annual Minimal Data Set (MDS), dated [DATE], indicated R23 was admitted to the care facility on 12/18/19, had moderate cognitive impairment and was dependent on staff for toileting and bathing and required touching assistance with personal hygiene. R23's Hospital Discharge summary, dated [DATE], indicated R23 was hospitalized on [DATE] and discharged back to the care facility on 12/31/24. A foley catheter was placed at the hospital on [DATE]. R23's Orders indicated a nursing order, dated 1/11/25, for staff to monitor urine output every shift. R23's Active Orders, printed 1/16/25, lacked any other order related to R23's foley catheter. R23's Associated Clinic of Psychology (ACP) note, dated 12/13/24, indicated several…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene and self-care was completed to promote a dignified appearance and reduce the risk of complication (i.e., scratches) for 3 of 4 residents (R23, R36, and R53) reviewed for activities of daily living (ADLs) and whom were dependent on staff for their care. Findings include: R53 R53's quarterly Minimum Data Set (MDS), dated [DATE], identified R53 had severe cognitive impairment, demonstrated no speech, and was unable or rarely able to be understood. Further, the MDS identified R53 was dependent on staff for nearly all self-care. R53's care plan, dated 11/22/24, identified R53 needed assistance with dressing and personal hygiene due to a history of stroke and hemiplegia (paralysis of one side). The care plan listed a goal which read, All my ADL needs will be anticipated and met by staff through the review date, and multiple interventions including assist of one with personal hygiene and, Staff to trim…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure care-planned interventions for activities of interest were provided or offered for 1 of 2 residents (R53) reviewed for activities and whom was non-verbal and unable to be understood. Findings include: R53's quarterly Minimum Data Set (MDS), dated [DATE], identified R53 had severe cognitive impairment, demonstrated no speech, and was unable or rarely able to be understood. Further, the MDS identified R53 was dependent on staff for nearly all self-care. R53's most recent Activity Assessment, dated 11/25/24, identified R53 was a Christian and listed a section labeled, Specific Leisure Interests, which marked R53 as having a preference for card games, active sports, classical and jazz music, television and movie interests, and social visits adding, Res. will have 1:1 [one to one] visits. A section labeled, Programming Information, outlined R53 preferred 1:1 visits and was unable to participate with passive participation marked.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure gastrostomy tube water flushes were provided per physician orders for 1 of 1 residents (R75) reviewed for tube feedings. Findings include: R75's quarterly Minimum Data Set (MDS) dated , 12/3/24 identified R75 was severely cognitively impaired, dependent on staff for all oral, toileting, personal hygiene, and mobility. In addition, R75 had diagnoses of a stroke (poor blood flow to a part of the brain causing cell death resulting in parts of the brain to function properly), diabetes, chronic obstructive pulmonary disease, respiratory failure, convulsions, gastrostomy (feeding tube inserted into the stomach), and a tracheostomy (surgical opening in the neck to allow a machine called a ventilator to help with breathing). R75's physician orders (PO) dated 11/2/24 stated, Tube Feeding: H2O (water) 150 milliliters[ml] per feeding tube q4hrs (every four hours). R75's care plan goal, dated 9/12/24 stated, Approach: Water flushes via GT [gastrostomy tube] per MD [physician]. During observation and interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and, if needed, develop interventions or implement appropriate pain monitoring to ensure comfort for 1 of 2 residents (R53) reviewed for pain management and whom was non-verbal and unable to communicate their needs. In addition, the facility failed to assess for and implement, if requested, non-pharmacological pain interventions for 1 of 2 residents (R70) reviewed for pain management. Findings include: R53 R53's quarterly Minimum Data Set (MDS), dated [DATE], identified R53 had severe cognitive impairment, demonstrated no speech, and was unable or rarely able to be understood. The MDS identified R53 was dependent on staff for nearly all self-care and outlined R53 consumed no scheduled medication or non-pharmacological interventions for pain management. However, the completed staff evaluation for pain on the MDS, located under Section J - Pain, identified staff had recorded, C. Facial expressions (grimaces, winces,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to attempt alternatives and ensure ongoing assessments for safety and appropriate use of side rails were completed for 1 of 1 resident (R18) who was observed to have side rails affixed to the bed. Findings include: R18's annual Minimum Data Set (MDS) dated [DATE], indicated R18 had moderately impaired cognition. R18's significant change MDS dated [DATE], indicated R18 had moderately impaired cognition. R18's quarterly MDS dated [DATE], indicated R18 had severely impaired cognition. R18's Restraint/Adaptive Equipment Use Observation was completed on 3/12/20 and 9/08/22. Both reports included assessments of R18 for side rail entrapment risk factors such as falls and medication use. The assessments indicated R18 had half side rails for bed mobility and assistance with transfers. R18's medical record was reviewed and lacked indication R18 was assessed for safety and appropriate use of side rails and alternatives were attempted since the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to complete comprehensive and ongoing behavioral monitoring (i.e., symptom or target behavior) for an administered antipsychotic medication to ensure efficacy of the medication for 1 of 5 residents (R62) reviewed for unnecessary medication use. Findings include: R62's quarterly Minimum Data Set, dated [DATE], identified R62 had severe cognitive impairment but demonstrated no delusional thinking, hallucinations, or other behaviors (i.e., physical, verbal, other) during the review period. Further, the MDS identified R62's consumed medications for the period which included both antipsychotic and antidepressant medication. On 1/14/25 at 9:05 a.m., R62 was observed while seated in a reclined high-back wheelchair in the commons area. R62 had multiple, red-colored scrapes on the left side of her face but was unable to verbally respond to questions when asked. R62 did not appear in distress at this time. Immediately following, at 9:09 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to implement appropriate infection control practices with proper glove use to prevent the spread of infection for 1 of 1 residents (R75) who was on enhanced barrier precautions (EBP) observed for tracheostomy care. Findings include: The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. Enhanced Barrier Precautions (EBP) is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing that lead to indirect transfer of MDROs from resident to resident. The article indicated EBP should be implemented (when contact precautions did not apply) for residents who are high risk for acquiring infections with wounds or indwelling medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to respond timely to ventilator alarms for 3 of 3 (R2, R3, R4) residents observed for ventilators. Findings include: R2's undated Face Sheet indicated diagnoses of chronic respiratory failure, heart failure, chronic obstructive pulmonary disease, persistent vegetative state, dependence on a respirator status, and personal history of sudden cardiac arrest. R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated he was severely cognitively impaired, and required total dependence for all cares and activities of daily living (ADLs). R2's care plan dated 10/30/24 indicated R2 was ventilator dependent and interventions included to answer vent alarms promptly. R3's undated Face Sheet indicated diagnoses of chronic respiratory failure, dependence on respirator status, encounter for attention to tracheostomy (a surgical opening into the neck to create an airway), persistent vegetative state, and chronic obstructive pulmonary disease. R3's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to monitor the development of pressure ulcers for 4 of 4 residents (R1, R2, R3, R4) reviewed for pressure ulcers. In addition, the facility failed to follow infection control practices during pressure ulcer care for 3 of 4 residents (R2, R3, R4) reviewed for pressure ulcers. Findings include: Definitions of pressure ulcer types according to National Pressure Ulcer Advisory Panel (NPUAP): Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis (middle layer of skin), presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Fat is not visible and deeper tissues are not visible. Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (non-viable usually moist tissue that can be soft and stringy in texture)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an allegation of abuse to the State Agency (SA) for 1 of 1 resident (R2) reviewed for allegations of abuse. Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency on 3/14/24, alleged R2 was physically and emotionally abused by unknown facility staff. The report identified R2 made posts on a social media website including Benedictine is a violence and woman hand head punched cried. R2's Minimum Data Set (MDS) dated [DATE], indicated R2 had diagnoses including aphasia, dementia, and cognitive social or emotional deficit following cerebral infarction (stroke). R2 had severely impaired cognitive skills for daily decision making and physical and verbal behaviors directed at others. R2 sometimes made herself understood and was sometimes able to understand others and required staff assistance with toileting, hygiene, and transferring. The facility's Concern report entry by registered nurse (RN)-A identified a concern…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to conduct and maintain records of a thorough investigation into an allegation of abuse for 1 of 1 resident (R2) reviewed for allegations of abuse. Findings include: R2's Minimum Data Set (MDS) dated [DATE], indicated R2 admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand and express speech), dementia, and cognitive social or emotional deficit following cerebral infarction (stroke). R2 had severely impaired cognitive skills for daily decision making and physical and verbal behaviors directed at others. R2 sometimes made herself understood and was sometimes able to understand others and required staff assistance with toileting, hygiene, and transferring. R2's care plan noted R2 was a vulnerable adult and needed assistance to remain safe within the community. The identified goal dated 3/28/24, was any suspected abuse will be investigated in a timely manor [sic] according to facility policy and procedures with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement enhanced barrier precautions (EBPs) for 2 of 3 (R3 and R4) residents observed for ventilator (machine that breathes for residents) tracheostomy residents, residents who had feeding tubes or indwelling urinary catheters. Findings include: R3's 5-day Minimum Data Set (MDS) dated [DATE], indicated R3 was in a persistent vegetative state and had diagnoses of traumatic brain injury, neurogenic bladder, history of multidrug-resistant organism (MRDOs), pneumonia, septicemia, seizure disorder or epilepsy and respiratory failure. R3 was dependent for all activities of daily living (ADLs). R3 had a tracheostomy and with invasive mechanical ventilator and required suctioning. R3 received tube feeding for nutrition and had an indwelling urinary catheter. Review of R3's care plan did not address R3's risk for infection nor interventions for infection prevention that included the use of personal protective equipment (PPE). During continuous…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-09 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure feeding tube (a tube inserted through the abdominal wall into the stomach or intestine) supplies including plastic syringes and graduated containers were disposed of in a timely manner to prevent contamination or infection for 5 of 6 residents (R39, R44, R49, R59, R64). In addition, the facility failed to ensure feeding tube nutrition was labeled according to standards of practice for 6 of 6 residents (R39, R44, R49, R53, R59 and R64) who received tube feeding nutrition. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 was unable to communicate or complete a Brief Interview for Mental Status (BIMS) and was dependent for all activities of daily living (ADLS). R39 received all nutrition through tube feeding. R39's diagnoses included toxic effect of carbon monoxide, asthma, herpes viral infection, coccyx (tail-bone) blisters, klebsiella pneumoniae (bacterial injection of the lungs), aspiration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-09 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and document review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments during medication pass observations for R15 one of eight residents reviewed for medication administration Findings include: During observation of the medication pass on 11/07/23 at 12:25 p.m., registered nurse (RN)-A placed a tray containing Tylenol two 500 milligram (mg) tablets and a Lispro insulin pen onto the top of the isolation cart outside R15's room, unattended while RN-A filled a mug of water from a spigot near the nursing station. RN-A returned a minute later and administered the medications. During interview on 11/07/23 at 12:32 p.m., RN-A stated, I should not have left the medications unattended. Review of the facility's policy titled, STORAGE OF MEDICATIONS revised 11/2018 revealed Medication supplies are locked when not attended by persons with authorized access.
- Potential for harm · E2023-11-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to ensure resident food stored in two nursing unit resident refrigerators was dated with an opened date and disposed of within professional standards. This involved two (third and fourth floor refrigerators) resident's refrigerators on two of the four nursing units. Findings include: During observation and interview on 11/06/23 at 12:56 p.m., the third-floor refrigerator located in the nursing medication room behind the nursing station contained an open quart container of prune juice not dated to indicate when it was open and a bag of food with resident's, R50's, name on it and dated 10/25/23. The director of dietary was present at the time of the observation and verified the prune juice had been opened and was not dated and the food with R50's name on it was dated 10/25/23 (12 days prior). She stated the food item should have been discarded. During observation and interview on 11/06/23 at 1:01 p.m., the fourth-floor resident refrigerator located in the nursing medication room behind the nursing station…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-09 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to maintain a clean, sanitary, homelike environment for 6 of 6 residents with tracheostomies (a surgical incision in the windpipe to allow for breathing) and feeding tubes (a tube placed through the abdominal wall into the stomach or intestine) (R39, R44, R59, R64, R48, R41) who had tube feeding residue on environmental surfaces and medical equipment. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 was unable to communicate or complete a Brief Interview for Mental Status (BIMS) and was dependent for all activities of daily living (ADLS). R39 received all nutrition through tube feeding. R39's diagnoses included toxic effect of carbon monoxide, asthma, herpes viral infection, coccyx (tail-bone) blisters, klebsiella pneumoniae (bacterial injection of the lungs), aspiration pneumonia, tracheostomy, history of methicillin resistant staphylococcus aureus (MRSA, a bacteria resistant to common antibiotics) in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-09 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure Level I Pre-admission Screening Assessments were completed for 2 of 2 residents (R4,R44). Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had intact cognition and was independent for all activities of daily living (ADLs). R4's diagnoses included paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally), anxiety, and major depression. R4's CAA dated 6/19/23, indicated R44 triggered for psychotropic drug use. R4's Pre-admission Screening Assessment (PAS) application dated 7/19/16, indicated Senior LinkAge Line did not complete the PAS and forwarded the PAS request to a county/managed care organization for PAS processing. No final review was received from the county/managed care organization. R44's quarterly MDS dated [DATE], indicated R44 had intact cognition, required set up assistance for eating and was dependent for all other ADLs. R44's diagnoses included major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 4 residents (R1) remained free from injury when he was transferred using a stand assist lift when the care plan directed a full body mechanical lift. R1 fell to the floor, and sustained a head laceration requiring staples. Findings include: R1's Diagnoses List dated 5/9/18 indicated R1 had diagnoses of Parkinson's Disease (progressive disease of the nervous system), dementia (progressive or persistent loss of intellectual functioning), dystonia (involuntary muscle contractions), and muscle weakness. R1's Minimum Data Set (MDS) dated [DATE] for significant change indicated R1 was totally dependent on two staff for transfers. R1's care plan dated 5/29/18 indicated R1 required total assist using full body mechanical lift for transfers. On 10/2/23 at 7:30 p.m., a facility investigation summary indicated R1 fell from an EZ Stand (stand assist lift) during transfer from the shower chair to bed. The report indicated by using the EZ Stand lift to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$84,774 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $84,774 — penalty dated 2024-05-23
- Medicare payment denial — starting 2024-06-19 for 37 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to BENEDICTINE HEALTH SYSTEM — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 22 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BENEDICTINE HEALTH SYSTEM | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/02/2000 |
| BENSON, JEFFREY | Individual | CORPORATE DIRECTOR | since 08/06/2014 |
| HACK, TAYLAR | Individual | CORPORATE DIRECTOR | since 07/01/2022 |
| HOEL, DAVID | Individual | CORPORATE DIRECTOR | since 09/01/2015 |
| PEARSON, LYNETTE | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| WILL, THERESA | Individual | CORPORATE DIRECTOR | since 02/01/2025 |
| BERGIEN, TRICIA | Individual | CORPORATE OFFICER | since 11/01/2016 |
| RYMANOWSKI, KEVIN | Individual | CORPORATE OFFICER | since 01/01/2008 |
| MIELKE, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/11/2025 |
| MOMANYI, PETER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/18/2025 |
CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 89% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245266. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-03, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.