Benedictine Care Community: Wound Infection Missed - MN
The inspection, completed September 25, 2025, focused on a single resident identified in records as R1. On September 1, 2025, nurses documented the drainage and the visible signs of localized infection at the incision site. Nobody called the doctor.
Purulent drainage at a wound site signals active infection. In elderly residents, the consequences can escalate quickly. Fever, a common warning sign in younger patients, is often absent in older adults, which makes early identification and antibiotic treatment especially critical. Inspectors noted that failing to contact a provider promptly, once those signs appeared, left R1 at risk for sepsis.
The facility's own wound care policy, dated September 2023, identified blood drainage in a chronic wound as a potential sign of increased microbial load, one that required an assessment for infection. The policy listed what nurses should watch for: erythema, hardening of tissue around the wound, increased or changed drainage, foul odor, heightened pain, delayed healing, confusion, loss of appetite, fever, and blood sugar changes in diabetic residents. The September 1 documentation reflected several of those markers.
A separate facility policy on change in condition, dated October 2023, directed licensed nurses to consult with the attending provider whenever a significant change in a resident's physical status was identified, and to document symptoms, observations, and provider notification. Inspectors found that did not happen here.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. The inspection was complaint-driven.
R1's condition on September 1 warranted a phone call. Whether that call was ever made, and what happened to the wound in the weeks that followed, the inspection report does not say.
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.
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 23, 2026 · Our methodology
BENEDICTINE CARE COMMUNITY in ADA, MN was cited for violations during a health inspection on September 25, 2025.
The inspection, completed September 25, 2025, focused on a single resident identified in records as R1.
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.