Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benedictine Living Community Of St. Peter during CMS and state inspections, most recent first.
The facility failed to document indications or diagnoses for medications prescribed to five residents, leading to a deficiency in ensuring drug regimens were free from unnecessary drugs. Residents with cognitive impairments and various medical conditions were prescribed multiple medications without documented purposes, despite being at risk for adverse reactions. The DON and consulting pharmacist acknowledged the lack of documentation, which was contrary to the facility's medication administration policy.
A resident with multiple health conditions, including vascular dementia, was found with Systane eye drops at their bedside without an assessment or physician's order for self-administration. Nursing staff confirmed the absence of necessary documentation and stated that the medication should have been stored in the medication cart, as per facility policy.
A resident with a history of dizziness, anemia, and diabetes was not provided with necessary vision services, as their eyeglasses required adjustment. Despite the resident's repeated requests and staff awareness, no timely action was taken to coordinate an appointment for the adjustment. The facility's policy on vision needs was not provided.
A resident with dementia and hypertension was administered a crushed metoprolol succinate extended release tablet without an order to do so, leading to a significant medication error. The medication aide and nursing staff confirmed the error, acknowledging that the extended release tablet should not have been crushed, as it disrupts the medication's intended use.
An LPN failed to perform appropriate hand hygiene during medication administration for two residents, one with impaired cognition and another with fractures. The LPN did not sanitize hands after glove removal or between resident interactions, contrary to facility policies. The nurse manager and infection preventionist confirmed the expectation for hand hygiene before and after resident contact.
The facility failed to document indications for psychotropic medications for two residents, leading to a deficiency. One resident with impaired cognition was prescribed buspirone and quetiapine, but only quetiapine had a specified diagnosis. Another resident with dementia and Parkinson's disease was prescribed sertraline without a documented indication. The Director of Nursing and consulting pharmacist acknowledged the lack of documentation, which was against the facility's medication administration policy.
Failure to Document Medication Indications for Residents
Penalty
Summary
The facility failed to identify diagnoses or indications for the use of medications for five residents, leading to a deficiency in ensuring that each resident's drug regimen was free from unnecessary drugs. Resident R37, with moderately impaired cognition and various behavioral issues, was prescribed multiple medications, including psychotropic drugs, without documented indications or diagnoses in the Physician Order Report or Medication Administration Record (MAR). Similarly, Resident R48, who had severe cognitive impairment and multiple diagnoses such as renal failure and diabetes, was also prescribed numerous medications without documented indications or diagnoses. Resident R59, who had no cognitive impairment but required assistance with daily activities and had diagnoses of dementia and Parkinson's disease, was at risk for adverse reactions due to high-risk medications that lacked documented indications or diagnoses. Resident R67, with moderately impaired cognition and diagnoses including hypertension and renal failure, was also prescribed medications without documented indications or diagnoses, despite being at risk for adverse reactions from psychotropic medications. Lastly, Resident R42, with severe cognitive impairment and Alzheimer's disease, was prescribed warfarin without a documented diagnosis or indication for use. The Director of Nursing (DON) confirmed that medications were expected to have indications or diagnoses on the MAR and provider orders to ensure staff knew the purpose of each medication. The consulting pharmacist stated that the provider was responsible for attaching a diagnosis to the medication order and that the facility should contact the provider if a medication order lacked a diagnosis. The facility's policy on administering medications emphasized the importance of ensuring safe administration with the indication for each medication order.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R65, was appropriately assessed and deemed suitable to self-administer medications. R65, who had diagnoses including cerebral infarction, muscle weakness, chronic kidney disease, and vascular dementia, was observed to have a bottle of Systane eye drops on the bedside table within reach. Despite the presence of these medications, there was no documented assessment or physician's order authorizing R65 to self-administer medications. Interviews with nursing staff, including a registered nurse and the nurse manager, confirmed that R65 did not have an order for self-administration and that the eye drops should have been stored in the medication cart. The director of nursing also stated that an assessment should have been completed to ensure R65's safety in having medications at the bedside. The facility's policy on self-administration of medications requires an interdisciplinary team assessment to determine if it is clinically appropriate and safe for a resident to self-administer medications. This assessment should be documented in the electronic medical record, which was not done in R65's case, leading to the deficiency.
Failure to Address Resident's Vision Needs
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain optimal visual abilities for a resident, identified as R2, who was reviewed for vision care. R2's medical history includes conditions such as dizziness, anemia, and type 2 diabetes. According to R2's admission minimum data set, R2 had adequate vision with the use of corrective lenses. However, observations on two consecutive days revealed that R2 was not wearing eyeglasses. During interviews, R2 expressed that the eyeglasses needed adjustment as they kept sliding down the nose, and this issue had been reported to the staff at the end of September. Despite R2's repeated requests for eyeglass adjustments, the facility staff did not take timely action. Nursing Assistant A confirmed that R2 had requested the adjustment, and the concern was communicated to the unit manager. LPN-B also acknowledged R2's request and mentioned that the adjustment needed to be done outside the facility, but no further action was taken. RN-A admitted to being aware of the issue but forgot to coordinate the necessary appointment and transportation for the adjustment. The facility's policy on vision or eyeglass needs was requested but not provided, indicating a lack of documented procedures to address such issues.
Significant Medication Error Due to Improper Crushing of Extended Release Tablet
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, identified as R15, had a diagnosis of unspecified dementia, muscle weakness, anxiety disorder, and essential primary hypertension. The resident required substantial assistance for daily activities and had severely impaired cognition. According to the physician's orders, R15 was prescribed metoprolol succinate extended release 25 mg tablet daily for high blood pressure. However, during an observation, a trained medication aide (TMA-A) was seen crushing the metoprolol succinate extended release tablet along with other medications for ease of swallowing, despite there being no order to crush this medication. Interviews with TMA-A, RN-A, the director of nursing, and a consulting pharmacist confirmed that the metoprolol succinate extended release tablet should not have been crushed, as it interferes with the medication's intended release mechanism. The facility's policy on administering medications requires that medications be administered in accordance with the orders, which was not followed in this case. The incident highlights a significant medication error due to the improper handling of the extended release medication without appropriate orders.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during medication administration for two residents. One resident, with moderately impaired cognition, required supervision with personal hygiene. During medication administration, an LPN applied eye drops, lidocaine, and administered a pill with applesauce without performing hand hygiene after removing gloves. The LPN then handled medication storage without sanitizing hands, and reused the applesauce for future medication administration. Another resident, admitted with hip and shoulder fractures, received medication from the same LPN who failed to perform hand hygiene before entering the resident's room. The LPN handled the resident's water mug with bare hands, refilled it, and returned it without sanitizing hands during the entire process. The LPN confirmed the lack of hand hygiene during the medication pass, stating it was not her usual practice to perform hand hygiene when gloves were used. The nurse manager and infection preventionist nurse confirmed that staff were expected to complete hand hygiene after glove removal, before entering or exiting a resident's room, and before the next medication administration. The facility's hand hygiene policy emphasized the importance of hand hygiene in preventing the spread of germs, and the medication administration policy required adherence to infection control procedures.
Failure to Document Indications for Psychotropic Medications
Penalty
Summary
The facility failed to identify diagnoses or indications for the use of psychotropic medications for two out of five residents reviewed for unnecessary medications. Resident R37, who had moderately impaired cognition and required substantial assistance with personal hygiene, was receiving psychotropic medications including buspirone and quetiapine. However, the Physician Order Report and Medication Administration Record (MAR) lacked indications for the use of buspirone, and only quetiapine had a specified diagnosis of delusional disorder. Similarly, Resident R59, who had no cognitive impairment but required assistance with daily activities and had diagnoses of dementia and Parkinson's disease, was prescribed sertraline without an indication for use or diagnosis documented in the MAR. Resident R67, with moderately impaired cognition and diagnoses of hypertension, renal failure, and dementia, was also receiving psychotropic medications such as buspirone and Lexapro without documented indications for use. The Director of Nursing acknowledged that medications were expected to have an indication or diagnosis on the MAR and provider orders. The consulting pharmacist stated that it was the provider's responsibility to attach a diagnosis to the medication order and that the facility should contact the provider if a medication order lacked a diagnosis. The facility's policy on administering medications emphasized the importance of ensuring safe administration with the indication for each medication order.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near St Peter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Le Sueur | 7.7 mi | — | 12 | 0 |
| Central Health Care Center | 12.6 mi | — | 3 | 0 |
| Oaklawn Care & Rehabilitation Center | 13.1 mi | — | 2 | 0 |
| Pathstone Living | 13.3 mi | — | 25 | 0 |
| Hillcrest Care & Rehabilitation Center | 14.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.