Cycle 1
Health 2025-08-07 · Fire 2025-08-07
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Duluth, MN
Ecumen Lakeshore
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4002 London Road, Duluth, MN
(218) 625-7100
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.70
Registered nurse staffing
LPN hours / resident day
0.46
Licensed practical nurse staffing
Aide hours / resident day
2.72
Nurse aide staffing
Weekend hours
4.29
Weekend nurse staffing
RN turnover
32%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.1% |
3.9%
5.2 pts worse
|
3.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
2.3%
0.5 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.5% |
5.4%
4.1 pts worse
|
5.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
88.6%
8.6 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.7% |
14.0%
3.7 pts worse
|
12.0%
5.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.9%
0.1 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
82.7%
12.6 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-09-08 · Fire 2023-09-08
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-22
F · Potential for more than minimal harm
2025-08-07
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-08-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-28
E · Potential for more than minimal harm
2025-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-08-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-09
F · Potential for more than minimal harm
2024-06-13
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 2024-06-25
F · Potential for more than minimal harm
2024-06-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-06-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-06-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-25
F · Potential for more than minimal harm
2023-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-01
D · Potential for more than minimal harm
2023-09-08
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 2023-09-25
D · Potential for more than minimal harm
2023-09-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-29
F · Potential for more than minimal harm
2024-06-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-25
D · Potential for more than minimal harm
2023-09-08
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-09
Penalties and ownership
What sits behind the stars
Ownership
Ecumen
5% Or Greater Direct Ownership Interest · Organization
Alam, Morshed
Operational/Managerial Control · Individual
Alam, Morshed
Corporate Director · Individual
Alam, Morshed
Corporate Officer · Individual
Cervenka, Debbie
Corporate Officer · Individual
Dady, James
Corporate Director · Individual
Kendrick, Shelley
Operational/Managerial Control · Individual
Kendrick, Shelley
Corporate Director · Individual
Kendrick, Shelley
Corporate Officer · Individual
Kendrick, Shelley
W-2 Managing Employee · Individual
Kro, Lisa
Corporate Director · Individual
Ulvestad, Nancy
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
Benedictine Health Center
Duluth, MN
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
#3
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
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