Benedictine Care Community

In the surveyor’s words

From the most serious findings on record at Benedictine Care Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 28, 2026

  Based on observation, interview and document review, the facility failed to provide adequate supervision and appropriately secure an exit door to prevent an elopement for 1 of 3 resident (R1) reviewed for elopement. This resulted in immediate jeopardy (IJ) when R1 left the facility without staff knowledge and was not located for approximately three hours.The immediate jeopardy began on [DATE] at 10:41 p.m., when R1 exited the facility through the north assisted living door. At 1:40 a.m., R1 was located laying in a row of trees across the road approximately 288 yards away from the facility. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 5:10 p.m. […]

• Immediate jeopardy, isolatedF684Mar 5, 2026

  Based 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. […]

• Actual harm, isolatedF684Sep 25, 2025

  Based 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. Findings include: R1's hospital Discharge summary dated [DATE], identified mechanical ground level fall after losing her balance and sustained a left subtrochanteric femur fracture. […]

• No harm, potential for more than minimal, widespreadF725Jun 10, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jun 10, 2026

  Based 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… […]