Benedictine Care Community: Wound Infection Missed - MN
A resident at Benedictine Care Community, identified in inspection records only as R1, had a left hip incision that nurses were expected to examine at least once per shift, every shift, checking the skin around it for the signs that signal an infection taking hold: redness, increased pain, drainage turning thick and foul. From August 27 through August 31, 2025, there was no documentation that any such assessment had been completed.
Then came September 1st.
That morning, or sometime that day, a nurse noted purulent drainage, redness, and tenderness around R1's left hip incision. Purulent drainage is not ambiguous. It is thick, often discolored, often foul-smelling, the body's signal that bacteria have colonized a wound. Redness and tenderness alongside it sharpen that signal considerably. A provider should have been contacted that day.
The inspection report does not say one was.
The facility's own infection prevention policy, dated September 2023, laid out exactly what nurses were supposed to do. Observe skin injuries daily. Document after every dressing change. Conduct a comprehensive wound assessment weekly, measuring length, width, and depth, noting the type of tissue present, recording the amount and character of any drainage. The policy specifically identified purulent drainage, erythema, increased pain, and changes in tissue character as localized signs of infection requiring assessment. The policy identified blood drainage in a chronic wound as a possible sign of increased microbial load. The policy existed, in writing, and described the situation nurses were facing with R1.
A separate facility policy on changes in condition, dated October 2023, required licensed nurses to contact the attending provider when a resident's physical status changed significantly, to implement any ordered treatment, and to follow up if no contact had been made within two hours.
Neither policy was followed in the days leading up to September 1st. Whether either was followed on September 1st itself, the inspection record does not resolve.
What the record does resolve is the stakes. Inspectors noted that early identification of an infection and prompt initiation of antibiotics matters specifically because of what delayed treatment can become: sepsis. Sepsis in elderly nursing home residents is not a theoretical risk. It is a documented, recurring cause of hospitalizations and deaths in long-term care settings, and it moves fast once it takes hold. A wound that could have been treated with a phone call and a prescription can, within days, become a systemic crisis.
The inspection classified the violation as causing actual harm to R1. Not potential harm. Not a risk of harm. Actual harm.
Inspectors spoke with a nurse at the facility who confirmed the gap herself: from August 27 through August 31, the documentation simply wasn't there. No skin assessment of R1's left hip incision. No record of anyone looking at the wound, checking the surrounding tissue, noting what the drainage looked like or whether the redness was spreading. The nurse acknowledged that assessments should have been completed at least once per shift and that the provider should have been contacted on September 1st when the drainage turned purulent.
The complaint inspection was conducted on September 25, 2025.
What happened to R1 after September 1st, whether antibiotics were eventually prescribed, whether the infection resolved or worsened, whether R1 required hospitalization, none of that appears in the inspection record. The report ends where the documentation ends: with a wound that had gone unmonitored for nearly a week, and a nurse confirming, on the record, that the call to the provider should have been made.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benedictine Care Community from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 12, 2026 · Our methodology
BENEDICTINE CARE COMMUNITY in ADA, MN was cited for violations during a health inspection on September 25, 2025.
From August 27 through August 31, 2025, there was no documentation that any such assessment had been completed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.