Benedictine Care Community

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide sufficient nursing staff to meet residents' assessed needs and provide required care and services. The facility's staffing shortages resulted in delayed toileting assistance, delayed eating assistance, loss of dignity, and transfers performed contrary to assessed needs and facility policy for 2 of 6 residents (R23, R24) reviewed in the sample requiring staff assistance with quality-of-care needs. The facility's ongoing staffing shortages had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to establish and maintain an infection prevention and control program that included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, the facility failed to timely initiate and consistently implement transmission-based precautions for 2 of 2 residents (R12. R24) reviewed who exhibited signs and symptoms of potentially infectious diarrhea; failed to consistently identify and monitor residents exhibiting signs and symptoms of potential infection through the facility's surveillance system for 2 of 2 residents (R7, R24) reviewed for infection surveillance; failed to ensure staff adhered to infection prevention practices related to hand hygiene for 1 of 3 residents (R24) reviewed for activities of daily living; [...]

Inspectors wroteBased on observation, interview and document review the facility failed to develop comprehensive, person-centered care plan to include enhanced barrier precautions (EBP) for 3 of 5 residents (R6, R7, R1) reviewed who were identified to be on EBP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignified care was provided for 1 of 1 resident (R24) reviewed for dignity. Staff encouraged R24 to remain incontinent rather than assisting her to the toilet when requested, resulting in embarrassment, and loss of dignity.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident grievance regarding a missing hearing aid was fully investigated, documented, resolved, and communicated to the resident representative in accordance with facility policy for 1 of 1 resident (R5) reviewed for grievances.

Inspectors wroteBased on interview and document review, the facility failed to review and justify continued use of an as needed (PRN) psychotropic medication for 1 of 5 residents (R8) who were reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide activities of daily living (ADL) care and services necessary to maintain residents' abilities by failing to provide timely toileting assistance for 1 of 6 residents (R24) reviewed who required staff assistance with toileting and transfers; and failed to provide timely supervision and assistance with eating for 1 of 6 residents (R23) reviewed who required staff assistance during meals.

Inspectors wroteDuring observation, interview, and document review, the facility failed to perform hand hygiene between glove changes during pressure ulcer wound care for 1 of 2 residents (R5) reviewed for pressure ulcers, creating the potential for contamination of pressure ulcer wounds and development of infection.

Inspectors wroteBased on interview and document review, the facility failed to ensure transfers were performed in accordance with assessed needs, care plan interventions, and facility policy for 1 of 3 residents (R24) reviewed for accidents. Staff performed transfers using a full-body mechanical lift with one staff member rather than the required two staff members, creating the potential for falls, entrapment, and transfer-related injury.

Inspectors wroteBased on interview and document review, the facility failed to ensure a reported medication error was investigated, documented, and addressed in accordance with facility policy for 1 of 5 residents (R37) reviewed for unnecessary medications. This deficient practice resulted in the facility's inability to determine the circumstances surrounding a reported Zepbound medication error, assess resident impact, and implement interventions to prevent recurrence.

Inspectors wroteBased on interview and document review, the facility failed to ensure consultant pharmacist recommendations regarding an irregularity in psychotropic medication use were addressed and resolved for 1 of 5 residents (R8) reviewed for unnecessary medications. The facility failed to ensure a required face-to-face practitioner evaluation occurred and allowed a PRN antipsychotic medication order to remain active and be administered despite repeated consultant pharmacist recommendations for review and discontinuation.

Inspectors wroteBased on observation, interview and document review, the facility failed to identify and act on a change of condition for 1 of 3 residents (R1) who was care planned for potential infections, had a fever and was experiencing hallucinations which was an atypical symptom. This delay in treatment resulted in an immediate Jeopardy (IJ) for R1 when she was diagnosed with sepsis and was hospitalized . The IJ began on 2/21/26, when R1's vital signs indicated a temperature of 101.7 degrees Fahrenheit (F) and she was demonstrating other signs of illness such as vomiting, visible shaking, hallucinations, disruptive behavior, reports of pain, and crying with no nursing assessment conducted and the provider was not contacted. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the infection preventionist (IP) completed the required training for the role of IP.

Inspectors wroteBased on interview and document review the facility failed to ensure physician notification of a change of condition for 1 of 3 residents (R1) reviewed who subsequently admitted to the hospital for septic shock.

Inspectors wroteBased on interview and document review the facility failed to ensure annual abuse training was completed for 2 of 10 staff reviewed for training. Findings Include:Nursing assistant (NA)-A had a hire date of 11/7/25. NA-A's record of Completed Training printed 3/5/26, indicated she had not completed annual abuse training. Registered nurse (RN)-B had a hire date of 8/28/24. RN-B's record of Completed Training printed 3/5/26, indicated she had not completed annual abuse training since 8/28/24. During interview on 3/5/26 at 1:41 p.m., the human resources manager (HRM) stated the mangers were responsible to ensure their staff completed training. The HRN said the corporate office sent messages quarterly regarding required trainings and she reminded the managers. The HRM said she did not track who had or had not completed required training. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure physician ordered medical supplies were available upon admission for 2 of 2 residents (R1, R2) reviewed who admitted to the facility with a catheter. In addition, the facility failed to obtain a physician's order prior to using an alternate catheter size.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R1) received necessary medical attention following a change in a left hip surgical incision. Additionally, the facility failed to comprehensively assess, monitor, and document skin changes. R1 sustained actual harm and required hospitalization, surgery, and insertion of a peripherally inserted central line catheter (PICC) for intravenous (IV) antibiotic treatment for sepsis.

Inspectors wroteBased on interview and document review, the facility failed to promptly notify a physician of a change in condition for 1 of 3 residents (R1) reviewed when a left hip surgical incision showed signs of infection and required hospitalization.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure activities of daily living (ADLs) were provided for 4 of 4 residents (R1, R2, R3, R4) who required assistance with bathing.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide restorative services for 4 of 4 residents (R1, R2, R3, R4) who discharge from Physical Therapy services with maintenance orders to maintain range of motion and conditioning. This had the potential to affect all 21 residents care planned for restorative therapy.

Inspectors wroteBased on observation, interview and document review the facility failed to meet resident care requests timely and promote resident dignity for 4 of 4 residents (R1, R2, R4) when call lights were not answered timely.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 5 of 5 residents (R1, R25, R35, R36 and R37) reviewed for grievances. This deficient practice had the potential to affect all 39 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 39 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R19) who was observed to self administer a nebulizer and had not been assessed as safe to self administer medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 1 residents ( R12) reviewed for activities of daily living (ADL)'s.

Inspectors wroteBased on interview and document review, the facility failed to accurately medication use in the Minimum Data Set (MDS) for 1 of 1 resident (R12) reviewed for MDS accuracy.

Inspectors wroteBased interview and document review, the facility failed to follow the most recent Centers for Disease Control (CDC) standards for offering and educating on pneumococcal vaccinations for 1 of 5 residents (R2) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide routine bathing/showering assistance for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for activities of daily living, and who were dependent on staff for assistance.