Benedictine Health Center Of Minneapolis
Benedictine Health Center Of Minneapolis in MINNEAPOLIS, MN — inspection on April 3, 2026.
Found 8 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 interview on 4/2/26 at 3:05 p.m., health unit coordinator (HUC) stated the nurses write the orders, then she transcribed them into the computer and gave back the order to the nurse to double check the accuracy of the order.
HUC stated all orders were always checked twice.
During interview on 4/2/26 at 3:00 p.m., licensed practical nurse (LPN)-A stated when a resident returned from a hospital, the nurse faxed the orders to the pharmacy. RN-E stated the nurses get the orders and the HUC or a nurse entered the orders on the computer.
Once the orders were entered into the computer, the orders were checked by two people.
During interview on 4/2/26 at 3:10 p.m., RN-E stated the nurses get physician orders, HUC entered the orders in the computer, and nurses verified the orders. RN-E added all orders were double checked. RN-E stated she knew she had to report medications errors and complete paperwork following facility policy.
During interview on 4/2/26 at 3:08 p.m., nurse manager RN-B stated on 10/20/25 R15 had seizures and was to the hospital for evaluation. R15 returned to the facility the same day with orders for Keppra 1000 mg twice a day. On 10/20/25 the Keppra order was transcribed by a nurse, but instead of 1000 mg the order was transcribed as 100 mg twice a day. R15 received 100 mg twice a day from 10/21/25 through 11/13/25. RN-B stated, on 11/13/26 R15 had another seizure, he was sent to the hospital for evaluation and returned the same day without new orders. R15 was to remain on 1000 mg of Keppra twice a day. On 11/14/25 RN-B received a call from R15's NP. NP was reviewing R15's 11/13/25 visit to the ER and realized a medication error had been made. RN-B received a verbal order for Keppra 1000 mg twice a day. RN-B stated she reported the medication error to the interim director of nursing and called the family. RN-B stated she didn't know if the medication error was reported to the SA.
During interview on 4/2/26 at 3:02 p.m., the administrator and the company's regional nurse indicated the transcription error was not reported because it was not clear this caused harm to R15, so the error was internally fixed and R15 was monitored for further seizure activity.Facility's policy titled Medication Errors dated 8/31/23, indicated when a medication error was made in the preparation or administration of a drug or biological, the licensed staff provides any necessary immediate care, and notifies the attending provider and resident or resident representative.
245266 04/03/2026
Benedictine Health Center of Minneapolis 618 East 17th Street Minneapolis, MN 55404
During an interview on 4/2/26 at 12:48 p.m., ADON/registered nurse (RN)-D stated they would expect nurses to complete the bed holds when a resident transferred to the hospital as if a resident wants their bed held, and it was important to do this. RN-D was unable to locate a completed bed hold for R12's 2/22/26 hospitalization.
During an interview on 4/3/26 at 10:05 a.m., administrator stated there was no further documentation for R12's bed hold to provide.A facility policy titled Bed Hold, reviewed 10/23, indicated Prior to or at the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident, responsible party, or legal representative written notice which restates and specifies the duration of the bed hold policy. If that is not possible due to extenuating circumstances (i.e. resident has gone to the hospital for an emergency), the Facility must communicate the information by telephone with the resident or responsible party/legal representative, and follow up by mailing the authorization/request form. A signature is not required on the written notice form, as long as the notice is issued to the resident or representative. If the notice is not signed, write the resident's name and how the notice was issued to the resident (e.g., resident unable to sign, or verbal consent by phone given by [name].
245266 04/03/2026
Benedictine Health Center of Minneapolis 618 East 17th Street Minneapolis, MN 55404
1 of 1 resident (R88) reviewed for a closed record.Findings include:R88 was admitted to the facility on
facility, she received therapy services and was discharged from the facility to her home.R88's discharge MDS dated [DATE] indicated, R88 was discharged to a short-term general hospital.R88's electronic medical record (EMR) included a progress note dated 2/9/26 at 3:33 p.m.
The progress note indicated R88 was discharged at 11:00 a.m. to her home with her sister. R88's sister provided transportation.
Note identified a local home health agency would provide home services.
Medication prescriptions were faxed to a local pharmacy, and R88 was discharged with medications as ordered.
R88's Discharge Plan of Care indicated R88 returned home on 2/9/26.During interview on 4/2/26 at 9:29 a.m., corporate MDS/registered nurse (CMDS) verified, the R88's discharge MDS indicated R88 was discharged to a hospital. CMDS stated the facility's MDS nurse made a coding error, CMDS added she will make a MDS modification.Requested a MDS policy but was not provided.
245266 04/03/2026
Benedictine Health Center of Minneapolis 618 East 17th Street Minneapolis, MN 55404
mobility.
The care plan had three sections: problem, goal and approach.The Problem section included
4/10/25, and indicated R24 still had a pressure area on his coccyx, left ear and right scapula.The
scapula.The Goal section dated 11/20/24 indicated resident's skin alteration will heal without infection.The Approach section included the following information:The approach section, dated 11/20/24 directed staff toEncourage adequate nutrition and hydration.Encourage adequate nutritionMonitor for indication of infection, contact MD if present.Physical therapy/occupational therapy for screening as appropriate.Treatment/dressing per MD orders.Turning and repositioning every 2-3 hours and as needed.
The approach section dated 9/26/25 directed staff,Use pillows for repositioning him off bony prominences including his coccyx, scapula and other areas prone to breakdown.Use specialty mattress and float his heels or use protectors.Positioning for comfort.The Care Plan report indicated the skin care plan was last reviewed/revised on 11/25/25 at 6:07 pm.
The care plan lacked interventions to address R24's ongoing skin changes.R24's Wound Care visit report dated 3/19/26, indicated R24 had a stage 2 pressure area on his left lateral distal leg, a stage 2 left lateral proximal leg, a stage 2 pressure area on his left ear and a right pressure area under the left side of the tracheostomy plastic part.R24's current physician orders included wound care orders for the pressure areas listed above.R24's Skin Assessments dated 3/23/26, and 3/30/26, indicated R24's skin was clean, dry and intact.During interview on 4/1/26 at 7:54 a.m., RN-A stated, R24 had several pressure areas and was seen weekly by the wound care specialist. RN-A stated the nurses were responsible for obtaining or receiving new wound care orders, but the care plan was updated by the nurse manager.During interview on 4/2/26 at 1:34 p.m., RN- B stated the care plans were updated as needed to reflect resident's medical changes. RN-B added the care plans were reviewed and updated when a MDS assessment was completed. RN-B verified the last time R24's approach section of the care plan was updated, was done on 9/26/25.
Between 9/26/25 and 4/1/26 R24 wounds and wound care orders were changed but the care plan was not updated. RN-B stated she expected the care plans would be accurate and reflected resident's problems, goals, and interventions.Facility's policy titled Comprehensive assessment and Care Planning dated 2/26/26, indicated a registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals, and sign and certify that the assessment was completed.
The assessment must accurately reflect the residents' status.
The policy also indicated the facility should use the results of the assessment to develop, review and revise the residents' person-centered comprehensive care plan.
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Benedictine Health Center of Minneapolis 618 East 17th Street Minneapolis, MN 55404
and evaluation was completed upon admission, with a change in physical function, or with an acute
The licensed nursing associate consulted with attending provider and notified the resident
245266 04/03/2026
Benedictine Health Center of Minneapolis 618 East 17th Street Minneapolis, MN 55404
During an interview on 4/2/26 at 9:12 a.m., R79 stated she feels dizzy at times which causes her to fall.
During an interview on 4/2/26 at 9:20 a.m., stated R79 had falls once and awhile and was able to ambulate independently around the facility and would call staff for help if she felt unsafe. R2 R2's significant change MDS, dated [DATE], indicated R2 was cognitively intact and dependent on staff for most ADLs.
The MDS further indicated R2 took antipsychotic medications during the look-back period. R2's orders, dated 2/5/26, indicated an order for clozapine (an atypical antipsychotic medication) 300 mg at bedtime for paranoid schizophrenia. R2's electronic medical record (EMR) lacked any evidence orthostatic blood pressure was being monitored.
During an interview on 4/2/26 at 11:10 a.m., clinical manager and registered nurse (RN)-B stated R2 had a fall with major injury and was currently only walking with physical therapy and was pivot transferring with staff. RN-B further stated R79 would fall if her blood pressure dropped, causing her to get dizzy. RN-B confirmed that neither R2 nor R79 had care planned or ordered interventions to monitor orthostatic blood pressure, stating it would be a good idea for R79 with her history of falls and dizziness.
During an interview on 4/2/26 at 2:10 p.m., the regional director stated it was expected that orthostatic blood pressure be monitored monthly for residents on antipsychotic medications. A facility policy titled Psychotropic Medication use, dated 9/7/23, indicated medication side effects to be monitored (i.e. orthostatic blood pressure.)
wear a gown and gloves. IP stated staff needed to use a gown and gloves when turning and
the community to protect residents and associates from the transmission of infectious diseases through use of appropriate precautions during resident care.
The policy also indicated EBP expanded to the use of PPE beyond situations in which exposure to blood and body fluids was anticipated. It also referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfers of multidrug-resistant organisms (MDROs) to staff's hands and clothing.
The facility's policy titled Contact Precautions dated 9/2023, indicated It is the policy of [company] to protect residents and associates from the transmission of infectious disease through use of appropriate precautions during resident care.
The policy also indicated contact precautions are used, in addition to standard precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact or by indirect contact of environmental surfaces of contaminated equipment.
245266 04/03/2026
Benedictine Health Center of Minneapolis 618 East 17th Street Minneapolis, MN 55404
During interview on 4/1/26
my patients.
During interview on 4/2/26 at 8:31 a.m., housekeeper aid (HA)-A stated he cleaned the
his department had a cleaning schedule. MD stated it was on a template, but he wasn't sure if the fans were included on the template. MD stated he did monthly rounds to check every room, but the fans were usually on, and it's difficult to determine if they were dirty when they are on. MD stated his expectation will be to check the fans every week and at least clean them monthly.
During interview on 4/2/26 at 1:34 p.m., RN-D stated the fans in residents' rooms should be cleaned to prevent dust blowing in their room. RN-D added, especially in the rooms of residents with tracheostomies and ventilators to minimize the risk of further respiratory problems.
Facility's procedure titled Resident Rooms-Routine Cleaning dated 11/2025, indicated maintaining clean and attractive surroundings without disrupting resident care.
The undated Room Survey form included observing the room environment and furniture, including fans to ensure they were cleaned and functional.
245266 04/03/2026
Benedictine Health Center of Minneapolis 618 East 17th Street Minneapolis, MN 55404
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MINNEAPOLIS, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Benedictine Health Center Of Minneapolis or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.