Benedictine Care Community

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

included the skin/incision each time to monitor for infection and make sure the incision was healing well without adhesions. The nurse would be expected to notify a provider right away when signs/symptoms of infection are noted such as fever, redness around incision, change in drainage, pain, change in mental status. Purulent drainage meant there was pus and infection present on 9/1/25 and a provider should have been called and documented. During an interview on 9/25/25 at 1:39 p.m. RN-D stated there was a noted change in Resident R1's left hip skin/incision on 9/1/25, charge nurse and the provider should have been notified.

There was an event created on 9/3/25, provider contacted but only for her foot. RN-D verified there was no skin/incision assessments completed from 8/27/25 through 8/31/25 (4 days) and should have been. On 9/1/25, documentation identified a changed in her incision, a decline, signs of infection which would have been considered a significant change. The nurse would have been expected to contact the provider and documented so that we could have followed up on it. Recognizing signs and symptoms of infection early was important. During an interview on 9/25/25 at 3:43 p.m. DON verified from 8/27/25 through 8/31/25, there was no documentation of a skin assessment on Resident R1's left hip incision and should have been completed at least once a shift to monitor for signs and symptoms of infection. The nurse would be expected to contact the provider right away when signs and symptoms of infection are seen such as increase in pain, drainage, purulent drainage, fever, and redness. The nurse can contact the provider by texting or calling depends on the provider and document. If it has been over two hours the nurse would be expected to follow up with the provider again so that continuity in care can be provided. The provider should have been contacted on 9/1/25 when purulent drainage, redness, and tenderness were noted on Resident R1's left hip incision area. Identification of an infection early and starting an antibiotic would be important to avoid sepsis. Facility policy Preventing Skin Infections dated 9/2023, identified the purpose was to promote wound healing while preventing infection. Drainage identified as sanguineous: blood drainage; blood drainage in a chronic wound may represent a sign of increased microbial load in the wound, which indicates an assessment for signs of infection was needed. Localized signs of infection would be erythema, induration (hardening of tissue around the wound site can indicate inflammation/infection), increased drainage, change in character of tissue, foul odor, increased pain at wound site, delayed wound healing, general malaise, mental confusion, loss of appetite, leukocytosis, fever (often not present in elderly), hypothermia, blood sugar changes in diabetic. Document progress toward healing following facility protocol

on when to request change of treatment. Facility policy Change in Condition dated 10/2/23, identified the provided care and services are based upon the current needs of the resident under the direction of the attending provider. When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative. Assess significant change in the resident's condition noted through direct observation, interview, or report for [sic] other staff. Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed. If unable to contact the physician, contact the medical director as appropriate. Document symptoms, assessment, observations, resident/resident representative, and medical provider notification.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Benedictine Care Community

201 9th Street West Ada, MN 56510

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

indicates an assessment for signs of infection was needed. Localized signs of infection would be erythema, induration (hardening of tissue around the wound site can indicate inflammation/infection), increased drainage, change in character of tissue, foul odor, increased pain at wound site, delayed wound healing, general malaise, mental confusion, loss of appetite, leukocytosis, fever (often not present in elderly), hypothermia, blood sugar changes in diabetic. Document progress toward healing following facility protocol

on when to request change of treatment. Facility policy Change in Condition dated 10/2/23, identified the provided care and services are based upon the current needs of the resident under the direction of the attending provider. When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative. Assess significant change in the resident's condition noted through direct observation, interview, or report for [sic] other staff. Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed. If unable to contact the physician, contact the medical director as appropriate. Document symptoms, assessment, observations, resident/resident representative, and medical provider notification.

Event ID:

Facility ID:

If continuation sheet