St Benedicts Health Center

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 16, 2026

  Based on observation, record review, review of professional reference, and staff interviews, the facility failed to ensure residents received the necessary care and services to attain the highest degree of safety and comfort for 2 of 4 sampled residents (Resident #10 and #88) reviewed for positioning and/or pain. Failure to ensure staff provided proper positioning while eating and at rest placed Resident #88 at risk for aspiration, choking, and discomfort. Failure to ensure staff reported signs and symptoms of pain/discomfort to the nurse in a timely manner resulted in Resident #10 experiencing avoidable pain during cares. Findings include: Swigert's The Source for Dysphagia, 4th Edition, 2019, Pro-Ed, Inc., Texas, page 130 stated, . […]

• No harm, potential for more than minimal, patternF800Jul 16, 2026

  Based on observation, review of facility policy, review of resident meal tickets, and resident and staff interviews, the facility failed to ensure each resident received a palatable meal and considered the preferences of each resident and their right to make choices about their diet for 5 of 27 sampled residents (Resident #4, #8, #9, #14, and #27) and 4 supplemental residents (Resident #19, #26, #28, and #81). Failure to accommodate resident choices and preferences may result in dissatisfaction with eating meals, decreased quality of life, and/or weight loss.Findings include: Review of the facility policy Resident Dining Areas occurred on 07/16/26. […]

• No harm, potential for more than minimal, patternF804Jul 16, 2026

  Based on observations, a sample test tray, and resident interviews, the facility failed to serve food at palatable and appetizing temperatures for 6 of 27 sampled residents (Resident #4, #11, #14, #27, #97, and confidential resident A) and 4 supplemental residents (Resident #46, #55, #81, and #115). Failure to serve food at a temperature acceptable and palatable to residents places the residents at risk of decreased food intake and has the potential to result in weight loss and nutritional decline. Findings Include: During interviews, the residents reported the following: - Resident A, The food is sometimes cold, delays in receiving meals, and stated, it depends on how much help they have. - Resident #4, Eats in the room, waits for meal delivery, and the food is cold, every meal. […]

• No harm, potential for more than minimal, patternF812Jul 16, 2026

  Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to store and serve food in accordance with professional standards of food safety in 1 of 1 kitchen and 1 of 3 dining rooms (main dining room). Failure to properly store thawing meat products, clean fans in the walk-in cooler, change soiled gloves when handling ready-to-eat food, and to properly store scoops in ice buckets has the potential to cause cross-contamination and may result in a foodborne illness for residents.Findings include: Review of the 2022 Food and Drug Administration Food Code identified the following: * Chapter 3, Section 3-304.15 Gloves, Use Limitation, pages 61-62, stated, . […]

• No harm, potential for more than minimal, isolatedF689Jul 16, 2026

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff provided adequate supervision to prevent accidents and/or injury for 1 of 1 sampled resident (Resident #79) with a risk and history of falls. Failure to ensure staff followed the care plan and provided adequate supervision placed the resident at risk for falls and/or injury. Findings include: Review of the facility's policy titled Integrated Fall Management occurred on 07/16/26. This undated policy stated, . 3. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the findings of the fall risk assessment. Review of Resident # 79's medical record occurred on all days of survey. […]