Benedictine Living Community Owatonna

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Oct 24, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Jul 24, 2024

  Based 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. […]

• Actual harm, isolatedF684May 13, 2026

  Based 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. […]

• Actual harm, isolatedF689Jul 9, 2025

  Based 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.Findings include:R1's face sheet dated 7/9/25, identified diagnoses of paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), acquired absence of left leg above the knee, and burst fracture of the T11-T12 vertebrae (a serious spinal injury when the vertebra breaks). […]

• Actual harm, isolatedF686Mar 10, 2022

  Based on observation, interview and document review the facility failed to comprehensively assess resident's skin to prevent facility acquired pressure ulcers and provide consistent skin monitoring for 1 of 3 residents (R28) reviewed for pressure ulcers. This caused actual harm for R28 who developed a stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough [non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed] may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.). […]