Benedictine Health Center: Care Plan Failures - MN
Resident 24 at Benedictine Health Center of Minneapolis had pressure areas documented on his coccyx, right scapula, right thigh and left thumb when his care plan was created in November 2024. By July 2025, inspectors found, he still had wounds on his coccyx and right scapula.
But his care plan approach section remained frozen in time. The last update came September 26, 2025, directing staff to "use pillows for repositioning him off bony prominences including his coccyx, scapula and other areas prone to breakdown" and "use specialty mattress and float his heels or use protectors."
By March 2026, Resident 24 had developed entirely new pressure sores. A wound care visit report from March 19 documented stage 2 pressure areas on his left lateral distal leg, left lateral proximal leg, and left ear. He also had a pressure area under the left side of his tracheostomy plastic part.
None of these new wounds appeared in his care plan.
The facility's own skin assessments from March 23 and March 30 claimed Resident 24's skin was "clean, dry and intact" — directly contradicting the wound care specialist's findings of multiple stage 2 pressure sores documented just days earlier.
RN-A told inspectors during an April 1 interview that Resident 24 "had several pressure areas and was seen weekly by the wound care specialist." She said nurses were responsible for obtaining new wound care orders, but the nurse manager updated care plans.
RN-B confirmed during an April 2 interview that care plans should be "updated as needed to reflect resident's medical changes" and reviewed when MDS assessments were completed. She verified that Resident 24's care plan approach section hadn't been updated since September 26, 2025.
"Between 9/26/25 and 4/1/26 R24 wounds and wound care orders were changed but the care plan was not updated," the inspection report stated.
RN-B told inspectors she expected care plans to be accurate and reflect residents' problems, goals, and interventions.
The original care plan from November 2024 had directed staff to encourage adequate nutrition and hydration, monitor for infection, provide physical therapy screening, follow physician treatment orders, and turn and reposition the resident every two to three hours.
By September 2025, the approach had been updated to include using pillows for repositioning and specialty mattresses. But as Resident 24's condition changed over the following months — developing new pressure areas on his legs and ear — the care plan remained static.
The facility received physician orders for wound care addressing the new pressure areas documented in March 2026. But staff continued following care plan instructions that were seven months old and made no mention of the leg and ear wounds requiring daily attention.
Inspectors noted that the care plan "lacked interventions to address R24's ongoing skin changes."
The facility's own policy, dated February 26, 2026, required registered nurses to conduct assessments that "accurately reflect the residents' status" and use assessment results to "develop, review and revise the residents' person-centered comprehensive care plan."
The care plan report showed Resident 24's skin care plan was last reviewed November 25, 2025 at 6:07 pm — still months before his new wounds developed.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for Resident 24, the outdated care plan meant staff lacked current guidance for treating wounds that had emerged on his legs and ear while his documented care approach focused on protecting areas where he no longer had active pressure sores.
The inspection was completed April 3, 2026.
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.
By July 2025, inspectors found, he still had wounds on his coccyx and right scapula.
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?
- By July 2025, inspectors found, he still had wounds on his coccyx and right scapula.
- 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.