Benedictine Care Community
201 9th Street West, Ada, MN 56510 · Norman County · 49 certified beds · avg 41 residents/day · certified since Nov 1, 1987
Part of chain: BENEDICTINE HEALTH SYSTEM (23 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 5, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 3, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 25, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 27, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 10, 2026 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Jun 10, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 10, 2026 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 10, 2026 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Mar 5, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 5, 2026 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 25, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Apr 9, 2025 | F · Potential for harm, facility-wide | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Apr 9, 2025 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Dec 20, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | E |
| 2024 | 2 | 0 | D |
| 2025 | 9 | 1 | G ▲ |
| 2026 | 16 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $154,460.
| Date | Type | Amount / length |
|---|---|---|
| Mar 5, 2026 | Fine | $154,460 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.78 | 4.83 | 3.95 | bottom 7% in Minnesota; top 50% in the U.S. |
| Registered Nurse hours | 0.90 | 1.22 | 0.69 | bottom 22% in Minnesota; top 21% in the U.S. |
| Weekend total nurse staffing | 3.34 | 4.27 | 3.50 | bottom 6% in Minnesota; bottom 49% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.69 | 0.48 | bottom 10% in Minnesota; bottom 41% in the U.S. |
| Total nursing staff turnover (%) | 60.4 | 42.2 | 45.8 | bottom 12% in Minnesota; bottom 16% in the U.S. |
| RN turnover (%) | 50.0 | 38.6 | 42.9 | bottom 32% in Minnesota; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.16, RN 0.75, weekend 2.79. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Anderson, Lisa | Individual | Corporate Director | NOT APPLICABLE | 11/16/2023 |
| Beitz, Rachel | Individual | Corporate Director | NOT APPLICABLE | 11/07/2019 |
| Benedictine Health System | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2008 |
| Bergien, Tricia | Individual | Corporate Officer | NOT APPLICABLE | 11/16/2016 |
| Carley, Gerald | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/03/2018 |
| Fischer, Hallie | Individual | Corporate Director | NOT APPLICABLE | 11/16/2023 |
| Hack, Taylar | Individual | Corporate Director | NOT APPLICABLE | 07/01/2022 |
| Holten, Tanner | Individual | Corporate Director | NOT APPLICABLE | 09/01/2021 |
| Hviding, Morgan | Individual | Contracted Managing Employee | NOT APPLICABLE | 07/25/2022 |
| Kappes, Colleen | Individual | Corporate Director | NOT APPLICABLE | 09/01/2021 |
| Luithle, Timothy | Individual | Contracted Managing Employee | NOT APPLICABLE | 01/01/2024 |
| Mykleseth, Kailey | Individual | Corporate Director | NOT APPLICABLE | 09/01/2021 |
| Palm, Ryan | Individual | Corporate Director | NOT APPLICABLE | 11/07/2019 |
| Ring, Bruce | Individual | Corporate Director | NOT APPLICABLE | 07/01/2016 |
| Rymanowski, Kevin | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Halstad Living Center | 14.1 mi | Halstad, MN | ★★★★☆ | 4/5 | |
| Viking Manor Nursing Home | 19.6 mi | Ulen, MN | ★★★★★ | 5/5 | |
| Fair Meadow Nursing Home | 19.8 mi | Fertile, MN | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245502.