Benedictine Living Community Owatonna

Inspectors wroteBased on observation, interview, and document review, the facility failed to educate on risk and prevention of deep vein thrombosis (DVT); failed to ensure applied compression wraps for DVT prevention were clarified upon admission for ongoing use; and failed to ensure physician orders for resumption of anticoagulant (blood thinning) medication were acted upon timely to help reduce the clotting risk for 1 of 3 residents (R1) reviewed. R1 was subsequently hospitalized and died due to severe blood clotting with an ischemic (insufficient blood flow) leg and pulmonary embolism (clot in the lung) resulting in actual harm for R1. In addition, the facility failed to ensure surgical incisions were adequately monitored by nursing staff to reduce the risk of complication (i.e., delayed response to infection) for 1 of 3 residents (R2) reviewed who had surgical wounds.

Inspectors wroteBased on interview and document review, the facility failed to develop a baseline care plan to ensure immediate care needs for surgical incision care and his urinary incontinence were addressed for 1 of 3 residents (R2) reviewed. R2's progress note, dated 4/13/26, identified R2 admitted to the care center and had several medical conditions including peripheral arterial disease (PAD), acute kidney injury, chronic kidney disease (CKD), and high blood pressure. R2 needed assistance for all activities of daily living (ADLs), needed cues and reminders to ask for help, and was alert and oriented to self. The note identified R2 had been incontinent of urine and was unaware of such. Further, the note included a section labeled Skin that identified, . two healing surgical sites in bilateral groin . Bruising to BUE [bilateral upper extremities] . [...]

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess and, if needed, develop a toileting program to promote urinary continence and reduce the risk of complication (i.e., skin infection, breakdown) for 1 of 3 residents (R2) reviewed. On 5/12/26 at 12:35 p.m., R2's family member (FM)-D was interviewed. R2 was admitted to the care center after being hospitalized for an extended period due to multiple conditions and he had used a catheter while in the hospital, but it was removed before he discharged to the care center on 4/13/26. FM-D stated R2 was doing good with using the bathroom and able to sense the need to go when he left the hospital. R2 also had some healing surgical incisions near his groin which were all intact and open-to-air (OTA). [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure high-risk medications were provided timely after being ordered to help prevent potential blood clots for 1 of 1 resident (R1) reviewed. R1 had Eliquis (an anticoagulant, blood thinning, medication) ordered by the medical doctor (MD)-A on 4/10/26; however, this was not provided to R1 until 4/12/26 despite supply of the medication available in the emergency kit (E-Kit) onsite. R1's Hospitalist Discharge summary, dated [DATE], identified R1 would be transitioned to the care center and listed a principal problem, Acute cholecystitis (gallbladder inflammation). R1's other active problems included high blood pressure, heart failure, and atrial fibrillation (irregular heart rhythm). [...]

Inspectors wroteBased on interview and record review the facility failed to timely implement physician's order to administer an anti-nausea medication and timely follow an order for transfer to emergency department for 1 of 3 residents (R1) which resulted in delay of treatment reviewed for change of condition.

Inspectors wroteBased on interview, and document review the facility failed to ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day for 1 of 1 resident (R2) reviewed for hospice services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper food temperatures and provide attractive food in order to ensure palatability for 15 of 15 residents (R2, R25, R26, R29, R45, R52, R55, R61, R63, R64, R69, R74, R75, R78, and R90) reviewed for concerns of cold food. In addition, the facility failed to provide palatable food for 4 of 4 residents (R22, R25, R47 and R78) reviewed for dining. This had the potential to affect all residents who ate food provided by the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure care was provided in a dignified manner for 1 of 2 residents (R24) reviewed for dignity, when the resident was left in bed, unclothed.

Inspectors wroteBased on observation and interviews the facility failed to provide a method for residents and resident representatives to submit grievances anonymously. In addition the facility failed to follow their grievance process for missing/damaged personal property for 1 of 1 resident (R69) who reported a missing item. This had the potential to prevent all 72 residents in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident status was accurately identified on the Minimum Data Set (MDS) assessment for 1 of 1 resident (R26) reviewed for mood and behaviors, specifically post traumatic stress disorder (PTSD).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure that medications were administered in accordance with accepted professional standards and failed to disinfect the rubber septum of an insulin pen with an alcohol wipe prior to attaching the needle and administering insulin for 1 of 1 resident (R87) observed during insulin administration.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 resident (R54) brief was changed according to his care plan, and who was reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview and document review, the facility failed to implement a process to ensure that the resident received their scheduled insulin dose while out of the facility for 1 of 1 resident (R90) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure an insulin pen included resident name and dated when opened for 1 of 1 resident (R87) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate treatment and services for a Foley catheter for 1 of 1 resident (R11) reviewed for catheter cares. In addition, the facility failed to follow proper infection control practices for 1 of 1 resident (R54) observed during peri care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure that the posted nurse staffing information accurately reflected the actual number of nursing assistants (NA) and the total number of hours worked for posted schedules. This had potential to affect all 74 residents or visitors who wished to review the information.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure safe transfers with a full body mechanical lift for 1 of 3 residents (R1) reviewed for falls/safety. This resulted in actual harm when R1 fell from the lift, had severe back pain, and needed to be sent to the emergency department (ED) for evaluation. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on observation, interview, and record review the facility failed to observe the rights of medication administration to ensure the right medication was safely administered for 1 of 3 residents (R2) reviewed for significant medication errors. This resulted in an immediate jeopardy for R2 who required hospitalization, continous monitoring and intravenous fluid recovery to return to baseline. The immediate jeopardy (IJ) began on 10/16/24 when licensed practical nurse (LPN)-A injected R2 with 100 units (U) of short-acting insulin instead of the prescribed Heparin (blood thinner that prevents blood clots) 5,000 milliliter (ml). The Administrator, Director of Nursing (DON), and clinical nurse manager were notified of the IJ on 10/23/24 at 5:13 p.m. [...]

Inspectors wroteBased on observations, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 4 of 9 residents (R8, R7, R9 and R6) observed during a medication pass. In addition, the facility failed to ensure proper cleaning of glucometer for 1 of 3 residents (R6) and failed to utilize enhanced barrier precautions (EBP) for 2 of 2 residents (R1 and R5) during wound dressing changes.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise the care plan for 2 of 9 residents reviewed (R1, R5) who had non-pressure related skin injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess, monitor, and notify the physician of new wounds for 2 of 3 residents (R1, R5) who had non-pressure related skin injuries.

Inspectors wroteBased on interview and record review the facility failed to follow the care plan for transfers for 1 of 3 residents (R1) who sustained a fall as a result.

Inspectors wroteBased on interview and document review the facility failed to safely use a mechanical lift per manufactures recommendations to transfer 1 of 1 resident (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to sustain a fractured sternum and left pelvic hematoma that required a hospital admission and blood transfusion. The IJ began on 7/21/24 at 9:40 p.m., when staff failed to ensure lift sling was properly secured prior to the transfer causing R1 to fall from the mechanical lift. The administrator, regional nurse manager, and director of nursing (DON) were notified of the IJ on 7/24/24 at 4:13 p.m. The IJ was removed on 7/22/24, when the facility implemented immediate corrective action before survey to prevent recurrence, therefore, the IJ was issued at past non-compliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the administrative staff and State Agency (SA) were notified immediately but no later than 2 hours of an allegation of neglect for 1 of 1 resident R1 who fell from a mechanical lift.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise the care plan for 1 of 4 residents (R1) observed who were identified to have behavioral issues not addressed in the care plan.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the infection control program used enhanced barrier precautions (EBP) for 5 of 5 residents (R7, R19, R9, R62 and R57) who had wounds or indwelling device present.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper infection control practices were followed, specifically hand hygiene, when culinary aides were observed failing to wear clean gloves or failing to wear gloves when handling food. This had the potential to impact all 30 residents who resided on Kindle and Oak units.

Inspectors wroteBased on observation, interview and document review the facility failed to provide a dignified dining experience for 1 of 1 resident (R57) who required a general soft and bite size texture diet. Findings Include: R57's face sheet dated 4/22/24, included diagnoses of hemiplegia and hemiparesis (mile to complete loss of strength on one side of the body) following cerebral infarction (stroke) affecting right dominant side. R57's Minimum Data Set (MDS) dated [DATE], indicated R57 usually is understood and understands. R57 had no behaviors and requires set up and cueing with eating and has no swallowing difficulty. R57's provider orders dated 3/25/24, included thin liquids, and 5/21/24, soft and bite size texture meals. R57's care plan dated 4/1/24, included alternation in nutrition/hydration related to multiple medical problems that may affect nutritional intakes. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure resident status was accurately identified on the Minimum Data Set (MDS) assessment for 2 of 2 residents (R62, R23) reviewed for mood and behaviors, specifically post traumatic stress disorder (PTSD).

Inspectors wroteBased on interview and document review, the facility failed to offer/provide a summary of the baseline care plan to the resident and/or resident representative for 2 of 2 residents (R57, R35) reviewed who were newly admitted to the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff provided restorative services to meet the assessed needs for 1 of 2 residents (R35) reviewed for restorative services.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess a resident for safe vaping practices for 2 of 2 residents (R7, R23) reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were following manufacturer's guidelines with continuous positive airway pressure (CPAP) machine with the use of distilled water for 1 of 1 resident (R62).

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and reassess past trauma and implement care plan interventions utilizing a trauma-informed approach for 2 of 2 residents (R64, R23), reviewed who had an active diagnosis of post-traumatic stress disorder (PTSD).

Inspectors wroteBased on interview and document review, the facility failed to ensure agency nursing assistants (NA's) received appropriate orientation and training prior to starting their first shift caring for residents. This had the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to act promptly and respond timely to concerns raised at resident council meetings for 5 of 10 residents, (R11, R50, R25, R6, R26) who attended council meetings.

Inspectors wroteBased on observation, interview and document review the facility failed to implement interventions to prevent potential worsening of contractures for 1 of 2 residents (R17) reviewed for contractures.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and develop individualized interventions to address exhibited behaviors of dementia for 1 of 1 resident (R43) observed to wander on unit and reported to go into other residents' rooms.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were securely stored, permitting only authorized personnel to have access for 4 of 4 residents (R62, R28, R37, R172) reviewed for medication storage. This had the potential to affect residents, visitors and staff who had access to the resident rooms.