Benedictine Health Center of Minneapolis

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for pressure ulcers. R1's hospital discharge summary note dated 6/11/26 identified R1's diagnoses included respiratory failure with hypoxia, anoxic brain damage and encephalopathy, very fragile with many skin tears/wounds to all extremities, a deep tissue pressure injury (DTPI) recurrent fevers/sepsis workup. R1's hospital wound care instructions dated 6/11/26 included:-Coccyx -zinc barrier two times a day (BID) and as needed (PRN) soiling.-Left lateral ankle - cleanse with normal saline (NS). Apply medical grade honey gel. Cover with mepilex dressing. Change Monday, Wednesday, Friday (MWF) and PRN soiling. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 is at risk of developing pressure ulcers (PU). [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to identify, monitor, and provide care consistent with professional standard of practice to an existing pressure injury for 1 of 3 residents (R1) reviewed for pressure sores. R1's hospital discharge summary note dated 6/11/26 identified R1's diagnoses included respiratory failure with hypoxia, anoxic brain damage and encephalopathy, very fragile with many skin tears/wounds to all extremities, a deep tissue pressure injury (DTPI) recurrent fevers/sepsis workup. R1's hospital wound care instructions dated 6/11/26 included the following:Left lateral ankle: Cleanse with normal saline (NS). Apply medical grade honey gel. Cover with mepilex dressing. Change Monday, Wednesday, Friday (MWF) and PRN (as needed) soiling. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 is at risk of developing pressure ulcers. [...]

Inspectors wroteThe facility failed to ensure transmission-based precautions were followed for 2 of 4 (R2 and R3) residents observed for proper infection control practices.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and document review, the facility failed to provide a bed hold notice for 1 of 1 residents (R12) reviewed for hospitalization.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.