St Benedicts Care Center

In the surveyor’s words

From the most serious findings on record at St Benedicts Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 8, 2026

  Based on interview and document review, the facility failed to follow manufacturer's recommendation and facility policy to ensure safe transfers with an EZ Way Smart Lift (mechanical, full body lift) for 1 of 3 resident (R1) reviewed for full body mechanical lift transfers. R1 fell out of the sling and sustained a laceration to his right eyebrow, was sent to the Emergency Department (ED), and required sutures. The facility implemented corrective action prior to the survey; therefore, the deficient practice was issued at past non-compliance.Findings included:R1's admission record dated 12/4/25, indicated R1's diagnoses included palliative care, wild-type transthyretin-related amyloidosis (build-up of abnormal proteins in tissues, such as heart and nerves), chronic kidney disease stage four… […]

• Actual harm, isolatedF689Nov 3, 2021

  Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to prevent reoccurring falls for 3 of 4 residents (R5, R2, R3) reviewed who resided in the Gardens Gate Unit. This resulted in harm for R5 when she sustained a right lower extremity fracture after an unwitnessed fall on 10/21/21, and was admitted to hospital for surgical intervention. Findings Include: R5's admission Minimal Data Set (MDS) dated [DATE], indicated R5 had diagnoses which included stroke, [CONDITION(S)] and no cognitive impairment. Further review of MDS, indicated R5 required limited assistance of one staff member for all activities of daily living (ADLS). […]

• No harm, potential for more than minimal, patternF812Aug 6, 2026

  Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 45 residents currently residing on the second floor.Findings Include:During observation and interview on 08/03/2026 at 10:28a.m., dietary assistant (DA)-A and surveyor reviewed contents of the Parker's Lane kitchenette on second floor. […]

• No harm, potential for more than minimal, patternF883Aug 1, 2024

  Based on interview and document review, the facility failed to ensure 4 of 5 residents (R21, R25, R28, R53) were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal… […]

• No harm, potential for more than minimal, patternF883Jun 16, 2022

  Based on interview and document review, the facility failed to revise their pneumococcal vaccine policy to current pneumococcal vaccination guidelines. This failure increased the risk for residents not vaccinated to contract pneumonia. Findings include: Review of a policy titled Pneumococcal Immunization, Long Term Care, dated 06/22, indicated .Residents will be offered the pneumococcal vaccinations and administered, according to the MDH and CDC recommended interval for the vaccines, unless contraindicated, already immunized, or the resident and/or the resident representative declines the vaccine.Definitions.Prevnar - PCV13 - Pneumococcal Conjugate 13 Valent.[MEDICATION(S)] - PPV23 - Pneumococcal Polysaccharide 23.Each resident's eligibility or contraindications to receive the pneumococcal… […]