Cycle 1
Health 2025-12-19 · Fire 2025-12-19
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Duluth, MN
Benedictine Health Center
1-star overall rating with 1-star inspections with abuse icon flag with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
935 Kenwood Avenue, Duluth, MN
(218) 522-8900
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
90
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
1980-11-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,502
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9872
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.25
Baseline 18.64% · Performance 20.39% · Measure score 2.25 · Achievement 2.25 · Improvement 0
Healthcare-associated infections
6.36
Baseline 5.08% · Performance 5.93% · Measure score 6.36 · Achievement 6.36 · Improvement 0
Total nurse turnover
1.36
Baseline 49.62% · Performance 58.12% · Measure score 1.36 · Achievement 1.36 · Improvement 0
Adjusted total nurse staffing
3.09
Baseline 4.46 hours · Performance 3.96 hours · Measure score 3.09 · Achievement 3.09 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.19% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 160 · Observed rate 4.38% · Lower 95% interval 5.68% |
| Discharge to community | 67.91% |
50.57%
17.3 pts better
|
Better than the National Rate · Eligible stays 142 · Observed rate 66.9% · Lower 95% interval 61.83% |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 242 · Denominator 242 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 242 |
| Discharge self-care score | 46.95% |
53.69%
6.7 pts worse
|
Numerator 100 · Denominator 213 |
| Discharge mobility score | 55.4% |
50.94%
4.5 pts better
|
Numerator 118 · Denominator 213 |
| Pressure ulcers or injuries, new or worsened | 2.07% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 242 · Adjusted rate 2.36% |
| Healthcare-associated infections requiring hospitalization | 5.93% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 3.64% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 3.68% |
8.2%
4.5 pts worse
|
Numerator 7 · Denominator 190 |
| Staff flu vaccination coverage | 65.69% |
42%
23.7 pts better
|
Numerator 134 · Denominator 204 |
| Discharge function score | 54.93% |
56.45%
1.5 pts worse
|
Numerator 117 · Denominator 213 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 120 · Denominator 120 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 40.3% |
25.2%
15.1 pts better
|
Numerator 54 · Denominator 134 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.4 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
97.3%
4.4 pts worse
|
93.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 97.1% · Q3 89.1% · Q4 89.2% · 4Q avg 92.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.8% |
96.1%
4.3 pts worse
|
95.5%
3.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.9%
3.5 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
4.3%
0.1 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.7% · Q3 5.2% · Q4 6.9% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
4.1%
2.3 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.2% · Q3 10.3% · Q4 1.9% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
12.4%
4.7 pts worse
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 17.7% · Q3 20.7% · Q4 15.1% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
17.5%
2.8 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.9% · Q3 15.6% · Q4 23.8% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.3% |
22.5%
10.8 pts worse
|
16.3%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
18.6%
1.8 pts better
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 25.0% · Q3 17.3% · Q4 4.3% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
2.3%
2.1 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 5.8% · Q3 0.0% · Q4 4.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
24.8%
2.5 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.7% · Q2 24.2% · Q3 21.8% · Q4 17.5% · 4Q avg 27.3% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
5.4%
6.1 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.4% · Q3 13.9% · Q4 13.0% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
88.6%
2.9 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 95.7% · Q3 92.0% · Q4 88.5% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
14.0%
0.3 pts better
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.9%
0.6 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.8% · Q3 2.3% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
82.7%
9.3 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
23.1%
1.7 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 18.3% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-07 · Fire 2024-11-07
0 health deficiencies
No concentrated health issue counts in this cycle.
12 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Cycle 3
Health 2023-10-19 · Fire 2023-10-19
7 health deficiencies
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-20
F · Potential for more than minimal harm
2025-12-19
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2026-01-20
F · Potential for more than minimal harm
2025-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-20
E · Potential for more than minimal harm
2025-12-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-20
F · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-11-07
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-11-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-11-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-11-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-11-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-11-07
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-11-07
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-11-07
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-11-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-25
F · Potential for more than minimal harm
2023-10-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-22
Inspection history
Recent health citations
K · Immediate jeopardy
2025-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-20
E · Potential for more than minimal harm
2025-12-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-20
C · Minimal harm
2025-12-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-20
J · Immediate jeopardy
2025-11-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
D · Potential for more than minimal harm
2025-05-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-30
D · Potential for more than minimal harm
2023-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-06-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-05
Penalties and ownership
What sits behind the stars
Ownership
Benedictine Health System
5% Or Greater Direct Ownership Interest · Organization
Benedictine Health System
Operational/Managerial Control · Organization
Bergien, Tricia
Corporate Officer · Individual
Bowe, Tia
Corporate Director · Individual
Carley, Gerald
Operational/Managerial Control · Individual
Eckes, Lois
Corporate Director · Individual
Fedora, Todd
Corporate Director · Individual
Hansen, Greg
Corporate Director · Individual
King, Dorene
Corporate Director · Individual
Kolar, John
Corporate Director · Individual
Kruchowski, Ramona
Corporate Director · Individual
Mccumber, Sara
Corporate Director · Individual
Palmolea, Nathan
Corporate Director · Individual
Pattock, Brian
Contracted Managing Employee · Individual
Pionk, Karen
Corporate Director · Individual
Rymanowski, Kevin
Corporate Officer · Individual
Spinler, Theresa
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Aftenro Home
Duluth, MN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Hilltop Healthcare Rehabilitation And Skilled Nurs
Duluth, MN
1-star overall rating with 2-star inspections with $244,730 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Ecumen Lakeshore
Duluth, MN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out