Benedictine Health Center of Minneapolis

In the surveyor’s words

From the most serious findings on record at Benedictine Health Center of Minneapolis, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 18, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF693Jan 24, 2022

  Based on interview and document review, the facility failed to ensure the head of bed was elevated for 1 of 3 residents (R1) who utilized a tube feeding to meet their nutritional needs. This resulted in an immediate jeopardy (IJ) situation for R1 who had an emesis when left flat in bed, while their tube feeding was running, which lead to aspiration and subsequent hospitalization . The IJ began on 1/15/22, at 3:10 p.m. while R1 was found laying flat in bed and covered in emesis when her tube feeding was actively running and was subsequently hospitalized due to an aspiration pneumonia. The administrator and director of nursing (DON) were notified of the IJ for R1 on 1/21/22, at 12:15 p.m. […]

• Actual harm, isolatedF686May 23, 2024

  Based 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. Findings include: Definitions of pressure ulcer types Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis (middle layer of skin), presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. […]

• No harm, potential for more than minimal, widespreadF880Apr 3, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF921Apr 3, 2026

  Based 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.Findings include: R63R63's annual Minimum Data Set (MDS) dated [DATE], indicated R63 was unable to speak, had moderately impaired decision making, and depended on staff members for all activities of daily living (ADLs). MDS indicated diagnoses of cardiorespiratory debility, tracheostomy, had a ventilator, and received oxygen and had a tube feeding. During observation on 3/30/26 at 5:35 p.m., R63 was sleeping in bed with her mouth open. A fan mounted on a wall was blowing air and there was dust accumulated on the grid. […]