Benedictine Care Community
BENEDICTINE CARE COMMUNITY in ADA, MN — inspection on June 10, 2026.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 6/9/26 at 11:29 a.m., trained medication aide (TMA)-A stated R24 should never wait when she had to go to the bathroom because R24 would then be incontinent. R24 should never be encouraged to go to the bathroom in her pants because that's not what R24 or any resident deserved.
Staff are expected to either request help from another staff member or to prioritize work to the best of their ability.
During an interview on 6/9/26 at 11:42 a.m., NA-C stated R24 cannot wait when R24 asked to use the bathroom.
When R24 turned on her call light, NA-C tried to get her to the bathroom right away because R24 would have an accident. R24 or any other resident should never be told to go in their pants because of dignity.
During an interview on 6/9/26 at 1:36 p.m., licensed practical nurse (LPN)-A stated a resident should never be told to just go in their pants because the residents have the right to receive their care.
During an interview on 6/9/26 at 2:06 p.m., registered nurse (RN)-A stated a resident should never be told to be incontinent. It was a dignity issue as well as an ADL issue. It's just wrong.
During an interview on 6/9/26 at 2:49 p.m., the director of nursing (DON) stated staff were expected to provide care when requested and to ensure all residents are safe.
Staff were also expected to never tell a resident to be incontinent because it was a dignity issue for the residents.The facility policy Activities of Daily Living (ADL) dated 2021, identified staff were directed to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
During an interview on 6/9/26 at 2:33 p.m., the social services designee (SSD) acknowledged receiving the grievance but stated it had been assigned to another person and no outcome had been communicated.
During an interview on 6/9/26 at 3:48 p.m., FM-A reported she had not received any updates or information regarding the grievance after filing the concern.
During an interview on 6/9/26 at 4:43 p.m., the director of nursing (DON) confirmed there was no documented follow-up and stated the expectation was that grievances would be resolved within five days and the complainant updated on progress and outcome.
The facility's Concerns and Grievances policy required investigation, resolution, communication with the complainant within five business days, ongoing updates when resolution was delayed, and documentation of actions taken.
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
changed for hospice patients, and it could go longer than fourteen days, but she always had them
consultant's pharmacist was telephoned on 6/9/26, at 5:56 p.m. and message left to return call.
he only reviewed medications for the facility for new admissions or hospital returns and was not the pharmacist that had done the monthly medication reviews for R8. CP-G stated it was his understanding the Center for Medicaid and Medicare (CMS) guidelines were that any PRN antipsychotic medication needed to be addressed by the physician The medication needed to be limited to fourteen days and re-evaluated by the provider. If the provider chose to continue the PRN antipsychotic medication, it would need to be evaluated with a face-to-face visit from the provider.
CP-G stated hospice was not an exception.
The facility's policy Psychotropic Medication Use with review date 9/7/23, identified PRN orders for psychotropic drugs were limited to fourteen days and could not be renewed unless the attending provider evaluated the resident for the appropriateness of the medication.
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
During an interview and observation on
caring for R7, we only needed to wear that for R7's roommate. NA-A then entered R7's room and proceeded to get R7 ready for the day. NA-A was not wearing a gown or gloves.
R1 R1's quarterly MDS dated [DATE], identified R1 had moderate cognition and had an indwelling catheter.
Diagnoses included renal insufficiency, urinary retention.
R1's care plan dated 5/22/26, included instructions to change catheter monthly, complete catheter care daily, and monitor for signs and symptoms of infection.
The care plan failed to include instructions for EBP related to catheter.
During observation on 6/9/26 at 7:23 a.m., a plastic cart was outside R1's room.
The cart contained disposable gowns and gloves, and a sign identifying R1 was on enhanced barrier precautions.
The sign included instructions for staff to wear gowns and gloves when performing direct care, including catheter care.
During interview on 6/10/26 at 5:16 p.m., DON stated EBP was used to prevent the spread of infections between staff/residents and helped to reduce the spread of multidrug-resistant organisms (MDRO's) whether they are known, suspected or potential.
The DON stated staff were expected to follow resident care plans and the facility policy regarding wearing PPE for EBP.
The Enhanced Barrier Precautions policy, revised 3/28/24, identified the purpose was to decrease transmission of CDC-targeted and other epidemiologically important MDRO's, and EBP would be used for residents actively infected or colonized with CDC-targeted and other epidemiologically important MDRO's.
Additionally, residents at risk for MDRO's, specifically those with an indwelling medical device and/or chronic wounds requiring a dressing would be required to use EBP.
The Comprehensive Assessments and Care Planning policy revised 2/26/26, identified a comprehensive person-centered care assessment of the resident's condition was completed in order to develop consistent quality care that would attain or maintain the highest practicable physical, mental and psychological functioning possible.
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Benedictine Care Community 201 9th Street West Ada, MN 56510
required supervision with eating would be watched and if the residents had stopped eating or had not
eating it would be realized quickly and assisted in a timely fashion. It is not dignified to sit there with
to assist with eating before bringing out the plate.
The facility policy Activities of Daily Living (ADL) dated 2021, identified staff were directed to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
Precautions policy dated 9/2023, identified hand hygiene is performed between glove changes and
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
p.m., the director of nursing (DON) stated no resident should be transferred with the full body
establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute
move a resident with a mechanical full body floor based mechanical lift or a ceiling/overhead full body lift.
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
reported this to administration many times and not had a response.
During an interview on 6/9/26 at
RN-A had spoken to the float staff individually and informed administration but had never documented
lights when they can safely leave the person they are caring for to check on the call light to ensure it's not a safety concern.
The DON also stated she had recognized the float staff didn't have accountability because the float didn't have an assigned resident group.
The DON planned to change assignments so each nursing assistant, including the float, would have an assigned group of residents.
This would include the float assigned residents from each unit.
That way, the float would be assisting on each unit and there would be a way to hold the float accountable for their work.
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
During an interview on 6/8/26 at 10:44 a.m., the director of nursing (DON) stated she had reviewed R37's medical record and R37's medication error investigation.
The DON stated there was a lapse in the process and an investigation was not completed.
The DON spoke with facility staff who explained the medication did not come from the pharmacy and R37 did not receive his dose of medication.
However, the event report stated wrong dose.
The DON stated investigation needed to be done to ensure what had occurred.
The staff were expected to complete an event report, then complete an investigation into what had happened.
This needed to be documented as well as interventions to prevent further medication errors.
During an interview on 6/9/26 at 2:15 p.m., registered nurse (RN)-A stated she vaguely remembered the event and attempted to review R37's medical record for further information. RN-A stated there was no documentation to explain what had occurred or actions taken. RN-A stated there should be a progress note, an event report, and a documented investigation into what happened.
Afterwards, it would be brought to IDT to discuss what had occurred and/or if further actions needed to be taken. An emailed response from the consultant pharmacist dated 6/10/26, identified the pharmacist expected facility staff to complete a thorough root cause investigation and analysis, appropriate follow-up, and detailed documentation for any medication error identified.
This should include assessment of the resident, physician notification when indicated, monitoring for adverse effects, and implementation of measures to help prevent recurrence. In the case of a resident receiving a one-time higher dose of tirzepatide (Zepbound), potential adverse effects may include gastrointestinal intolerance such as nausea, vomiting, diarrhea, abdominal discomfort, and decreased appetite.
Conversely, if a resident receives a lower-than-ordered dose, potential concerns may include less effective appetite suppression, and possible elevations in blood glucose for residents using the medication for glycemic control.
The facility policy Medication Error/Occurrence dated 2021, identified When an error is made in the preparation or administration of a drug or biological, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation or treatment is indicated.
Medication errors are tracked and trended for quality improvement purposes.
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Benedictine Care Community 201 9th Street West Ada, MN 56510
limited to fourteen days and re-evaluated by the provider. If the provider chose to continue the PRN
6/10/26, at 4:30 p.m. CP-H wrote she had made recommendations to R8's primary provider both in
reviewed them. In addition, CP-H had emailed the DON and the facility's medical director to reiterate that all PRN antipsychotic medications were subject to an initial 14 day stop date requirement unless a documented face to face evaluation was completed.
The order for the PNR haloperidol was discontinued on 6/9/26, However, the discontinuation of the medication was after interviews were completed regarding the continued use of the PRN medication.
The facility's policy Psychotropic Medication Use with review date 9/7/23, identified PRN orders for psychotropic drugs were limited to fourteen days and could not be renewed unless the attending provider evaluated the resident for the appropriateness of the medication.
During an observation on 6/7/26 at 12:11 p.m., NA-B unfastened R24's incontinent brief and used disposable wipes to clean R24's skin of feces and urine. R24 stated that her skin was itchy, NA-B told R24 that R24 had pooped and NA-B would clean R24's skin well. At 12:13 p.m., NA-B rolled R24 to the right and R24 began crying and stated, I can't do this. NA-B told R24 that they were almost done.
R24's skin on her upper thighs and buttocks was reddened but had no open areas. NA-B applied barrier cream then a clean brief. NA-B used disposable wipes to clean her gloves. NA-B did not remove her gloves nor use hand sanitizer.
During an interview on 6/7/26 at 12:28 p.m., NA-B stated she had removed her gloves an
245502 06/10/2026
Benedictine Care Community 201 9th Street West Ada, MN 56510
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.