Benedictine Care Community: Medication Error Uninvestigated - MN
The resident, identified in inspection records only as R37, had morbid obesity, cerebral palsy, and obstructive sleep apnea, and had been prescribed Zepbound, a once-weekly injectable medication used for chronic weight management. The April 23 event report noted a wrong dose on April 22. Beyond that, the medical record contained nothing. No investigation. No progress note. No physician notification. No assessment of whether R37 had been harmed.
When inspectors interviewed the director of nursing on June 8, she acknowledged the failure directly. She said she had reviewed the record and found no completed investigation. Staff told her the medication had not come from the pharmacy and that R37 had not actually received his dose, but that account was never documented, and it contradicted the event report, which stated wrong dose. The director of nursing said an investigation still needed to be done.
The nurse who filed the original report told inspectors on June 9 that she vaguely remembered the event and found nothing in the record to explain what had occurred or what anyone had done about it.
The facility's consultant pharmacist, responding by email on the day inspectors completed their review, laid out what a proper response would have looked like: a root cause investigation, resident assessment, physician notification when indicated, monitoring for adverse effects, and documented measures to prevent recurrence. A resident who received a higher-than-ordered dose of tirzepatide, the drug's active ingredient, could experience nausea, vomiting, diarrhea, or abdominal pain. A lower dose could mean reduced appetite suppression or elevated blood glucose.
Whether R37 received too much, too little, or nothing at all remained, as of the inspection, an open question nobody at the facility had tried to answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benedictine Care Community from 2026-06-10 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
BENEDICTINE CARE COMMUNITY in ADA, MN was cited for violations during a health inspection on June 10, 2026.
The April 23 event report noted a wrong dose on April 22.
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.