Benedictine Health Center

Inspectors wroteBased on interview and document review, the facility failed to ensure the medical provider was updated in a timely manner about worsening edema which needed additional nursing interventions to manage for 1 of 3 residents (R1) reviewed who had heart failure. R1 developed edema in their legs which caused the nurses to place Tubigrips (a compression-style device) on them, however, the medical provider was not immediately updated about this.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure infection control interventions were implemented during an outbreak of SARS-CoV-2 (COVID), according to nationally recognized standards of practice such as Centers for Disease Control and Prevention (CDC) guidelines, including contact tracing and testing of staff and residents per guidelines. In addition, the facility staff failed to utilize proper personal protective equipment (PPE) while caring for COVID-positive residents and ensure that equipment was properly sanitized following use in a COVID-positive resident room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the proper labeling of medications and the removal of expired medications and supplies occurred in two of two medication rooms and 3 of 6 medication carts. This deficient practice had the potential to impact all residents who received supplies and medications from reviewed medication rooms and carts.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a dignified dining experience was provided for 1 of 11 residents (R16) observed during dining while staff stood next to them while assisting them with eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident choice to refuse when medication was hidden in food for 1 of 5 (R46) residents reviewed for resident rights. In addition, the facility failed to ensure 1 of 2 residents (R34) with a vision deficit was assisted in selecting menu choices when they were unable to do so independently.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate privacy was in place prior to and after 1 of 1 resident (R75) had requested privacy measures be implemented for privacy during toileting and self-cares performed in bed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of chemical restraints and utilized/documented nonpharmacological interventions prior to administering as needed psychotropic medications. The facility also failed to have a stop date for as needed psychotropic medications that were past 14 days and did not have a stop date documented. This effected 2 of 6 (R46, R69) residents looked at for unnecessary medications. Findings Include: R46: R46's quarterly Minimum Data Set, dated [DATE], indicated R46 had moderate cognitive impairment. Diagnoses included dementia, encephalopathy, and epilepsy. R46's care plan dated 12/8/25, indicated a psychosocial well-being concern related to potential for trauma related to my past military service and may become agitated or aggressive. [...]

Inspectors wroteBased on observation, interview, and document review the facility staff failed to have qualified staff administer medications to a resident. This effected 1 of 1 (R46) resident reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure morning cares including oral cares were completed for 1 of 3 residents (R62) reviewed for activities of daily living (ADLs), and who were dependent on staff for assistance with ADL cares.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a locked door on the secure memory care unit had a functioning alarm to prevent residents at risk for elopement from leaving unobserved. This affected 1 of 2 residents (R100) reviewed for elopement risk.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the nursing staff posting included the facility name and was updated with changes in staffing. In addition, the facility included the director of nursing and the nurse managers (who were not responsible for direct resident care) in the total hours worked. This had the potential to affect 96 residents and their visitors.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 resident (R1) was free from sexual abuse when nursing assistant (NA)-A entered R1's room with his genitals exposed to R1 and proceeded to hold R1's hand while holding his genitals in his other hand. This had the potential to result in serious psychosocial harm for R1. The IJ began on 10/22/25, at approximately 5:00 a.m., when NA-A entered R1's room and sexually abused R1. NA-A exposed his genitals to R1 through his unzipped pants and held R1's hand with one hand while holding his genitals in his other hand. The administrator and the director of nursing (DON) were informed of the IJ on 10/29/25, at 3:36 p.m. The facility had implemented corrective action to prevent recurrence by 10/22/25, therefore, F600 is being issued at past non-compliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to report an injury of unknown origin to the State Agency (SA) immediately, but not later than two hours, for 1 of 4 (R1) residents reviewed for resident safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper glove use and hand hygiene was performed during incontinence care for 1 of 4 (R3) residents reviewed for incontinence care.

Inspectors wroteBased on interview and document review, the facility failed to conduct ongoing surveillance for the infection control program to ensure tracking and trending of infections and illnesses in the facility. This deficient practice had the potential to affect all 87 residents currently residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R30, R49, R71, R73) reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure timely repositioning was offered for 1 of 6 residents (R74) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a restorative range of motion program for 1 of 4 residents (R14) reviewed for range of motion and who was assessed as needing a range of motion program to promote mobility.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 4 residents (R7) reviewed for weight loss.