Benedictine Health Center
935 Kenwood Avenue, Duluth, MN 55811 · St. Louis County · 96 certified beds · avg 91 residents/day · certified since Nov 17, 1980
Abuse citation flag (CMS)
Part of chain: BENEDICTINE HEALTH SYSTEM (23 facilities, chain avg rating 2.8★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
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, repeated · Dec 19, 2025 · F-0880
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.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jan 20, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 25, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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.
All citations in the current public record (19)
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 |
|---|---|---|
| May 27, 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 |
| Dec 19, 2025 | ▲ K · Immediate jeopardy, repeated | 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. |
| Dec 19, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive. |
| Dec 19, 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. |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Nov 25, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 15, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 20, 2023 | D · Potential for harm, one-off | 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. · from a complaint |
| Oct 19, 2023 | 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. |
| Oct 19, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Oct 19, 2023 | 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. |
| Oct 19, 2023 | D · Potential for harm, one-off | 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. |
| Oct 19, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | F |
| 2025 | 12 | 2 | K ▲ |
| 2026 | 1 | 0 | D |
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)
No fines or payment denials in the published 3-year window.
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) | 4.31 | 4.83 | 3.95 | bottom 30% in Minnesota; top 29% in the U.S. |
| Registered Nurse hours | 0.87 | 1.22 | 0.69 | bottom 19% in Minnesota; top 22% in the U.S. |
| Weekend total nurse staffing | 3.74 | 4.27 | 3.50 | bottom 27% in Minnesota; top 32% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.44 | 0.69 | 0.48 | bottom 27% in Minnesota; top 41% in the U.S. |
| Total nursing staff turnover (%) | 51.8 | 42.2 | 45.8 | bottom 23% in Minnesota; bottom 32% in the U.S. |
| RN turnover (%) | 45.0 | 38.6 | 42.9 | bottom 36% in Minnesota; bottom 44% 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 3.94, RN 0.80, weekend 3.42. Staffing rating: 4/5.
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: 4/5 · long-stay residents: 3/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Benedictine Health System | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/05/1985 |
| Bergien, Tricia | Individual | Corporate Officer | NOT APPLICABLE | 05/04/2020 |
| Bowe, Tia | Individual | Corporate Director | NOT APPLICABLE | 04/30/2019 |
| Carley, Gerald | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/03/2018 |
| Eckes, Lois | Individual | Corporate Director | NOT APPLICABLE | 10/01/2015 |
| Fedora, Todd | Individual | Corporate Director | NOT APPLICABLE | 12/01/2015 |
| Hansen, Greg | Individual | Corporate Director | NOT APPLICABLE | 12/01/2013 |
| King, Dorene | Individual | Corporate Director | NOT APPLICABLE | 10/01/2011 |
| Kolar, John | Individual | Corporate Director | NOT APPLICABLE | 01/29/2019 |
| Kruchowski, Ramona | Individual | Corporate Director | NOT APPLICABLE | 01/29/2019 |
| McCumber, Sara | Individual | Corporate Director | NOT APPLICABLE | 12/01/2014 |
| Palmolea, Nathan | Individual | Corporate Director | NOT APPLICABLE | 04/01/2017 |
| Pattock, Brian | Individual | Contracted Managing Employee | NOT APPLICABLE | 11/02/2017 |
| Pionk, Karen | Individual | Corporate Director | NOT APPLICABLE | 11/30/2017 |
| Rymanowski, Kevin | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2008 |
| Spinler, Theresa | Individual | Corporate Director | NOT APPLICABLE | 10/01/2009 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "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 |
|---|---|---|---|---|---|
| Aftenro Home | 0.4 mi | Duluth, MN | ★☆☆☆☆ | 1/5 | |
| Hilltop Healthcare Rehabilitation and Skilled Nurs | 1.3 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Ecumen Lakeshore | 2.8 mi | Duluth, MN | ★★★★★ | 5/5 | |
| Bayshore Residence and Rehabilitation Center | 3.2 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Viewcrest Health Center | 3.5 mi | Duluth, MN | ★★★☆☆ | 3/5 | |
| Franciscan Health Center | 5.2 mi | Duluth, MN | ★☆☆☆☆ | 2/5 | |
| Dove Healthcare - Superior | 6.8 mi | Superior, WI | ★★☆☆☆ | 2/5 | |
| Villa Marina Health and Rehabilitation Center | 7.5 mi | Superior, WI | ★★★★☆ | 3/5 | |
| The North Shore Estates LLC | 7.7 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Twin Ports Health Services | 8.2 mi | Superior, WI | ★★★★★ | 4/5 | |
| Interfaith Care Center | 18.2 mi | Carlton, MN | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245236.