Benedictine Health Center: Fall Monitoring Failures - MN
Federal inspectors found the facility failed to track orthostatic blood pressure for residents R79 and R2, despite both having documented histories of falls and taking medications that can cause dizziness and fainting. The oversight violated the facility's own policy requiring such monitoring.
R79 told inspectors she "feels dizzy at times which causes her to fall." Her medical records documented five separate incidents between January and March 2026. On March 17, staff found her sitting on the bathroom floor after she "lowered herself to the floor after she felt dizzy." Three weeks earlier, she fell coming inside from the smoking area. On January 22, staff discovered her on the floor outside the smoking area.
The resident took two different antipsychotic medications. Her orders showed lurasidone 40 milligrams daily for schizophrenia and risperidone 5 milligrams twice daily for bipolar disorder. Despite this combination therapy and her repeated falls, her electronic medical record contained no evidence of blood pressure monitoring.
Staff recognized the connection between R79's medication and her symptoms. Progress notes from March 24 directed staff to provide her with a water pitcher at the beginning of each shift "to help manage her blood pressure." Yet no formal monitoring protocol existed.
R2 experienced more severe consequences. The cognitively intact resident, who required staff assistance for most daily activities, suffered what a clinical manager described as "a fall with major injury." The incident left R2 able to walk only during physical therapy sessions and requiring staff assistance for transfers.
Like R79, R2 took antipsychotic medication. Her orders showed clozapine 300 milligrams at bedtime for paranoid schizophrenia. Her medical record also lacked any evidence of orthostatic blood pressure monitoring.
Clinical manager RN-B acknowledged the oversight during interviews with inspectors. She confirmed that neither resident "had care planned or ordered interventions to monitor orthostatic blood pressure," adding it "would be a good idea for R79 with her history of falls and dizziness."
RN-B understood the medical connection, stating that "R79 would fall if her blood pressure dropped, causing her to get dizzy."
The facility's regional director told inspectors that orthostatic blood pressure monitoring was "expected" to occur monthly for residents on antipsychotic medications. This expectation aligned with the facility's own written policy on psychotropic medication use, dated September 7, 2023, which specifically listed orthostatic blood pressure among the side effects requiring monitoring.
Medical literature supports the need for such monitoring. A 2018 National Library of Medicine article cited in the inspection report noted that elderly patients face particular risks from antipsychotic medications. "All antipsychotics carry some risk of orthostatic hypotension," the article stated, which "can lead to dizziness, syncope, falls."
The article emphasized that orthostatic hypotension "should be evaluated by both history and measurement," particularly for patients with risk factors including age, diabetes, alcohol dependence, Parkinson's disease, dehydration, and drug interactions.
Both residents remained cognitively intact throughout their care, according to their Minimum Data Set assessments. R79 maintained independence with most daily activities, while R2 required more assistance but retained full cognitive function.
The inspection found that despite having clear policies, documented falls, resident complaints of dizziness, and staff recognition of the problem, the facility never implemented the basic safety monitoring that could have prevented injuries.
R79 continues to experience dizziness and falls. R2 remains limited to walking only during physical therapy sessions, a stark contrast to her previous mobility level before the major injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benedictine Health Center of Minneapolis from 2026-04-03 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Benedictine Health Center of Minneapolis
- Browse all MN nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
Benedictine Health Center Of Minneapolis in MINNEAPOLIS, MN was cited for violations during a health inspection on April 3, 2026.
The oversight violated the facility's own policy requiring such monitoring.
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.
Frequently Asked Questions
- What happened at Benedictine Health Center Of Minneapolis?
- The oversight violated the facility's own policy requiring such monitoring.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MINNEAPOLIS, MN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Benedictine Health Center Of Minneapolis or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 245266.
- Has this facility had violations before?
- To check Benedictine Health Center Of Minneapolis's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.