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
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
1.70
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.88
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.16
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.29
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.38
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.68
CMS adjusted RN staffing hours
Adjusted total hours
4.83
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,321
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.17% · Performance 23.88% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.51
Baseline 5.03% · Performance 7.08% · Measure score 2.51 · Achievement 2.51 · Improvement 0
Total nurse turnover
3.66
Baseline 35.82% · Performance 48.72% · Measure score 3.66 · Achievement 3.66 · Improvement 0
Adjusted total nurse staffing
5.87
Baseline 5.63 hours · Performance 4.75 hours · Measure score 5.87 · Achievement 5.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 413 · Observed rate 8.23% · Lower 95% interval 7.34% |
| Discharge to community | 70.18% |
50.57%
19.6 pts better
|
Better than the National Rate · Eligible stays 385 · Observed rate 73.77% · Lower 95% interval 66.03% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.64% |
95.27%
2.6 pts worse
|
Numerator 529 · Denominator 571 |
| Falls with major injury | 1.05% |
0.77%
0.3 pts worse
|
Numerator 6 · Denominator 571 |
| Discharge self-care score | 63.6% |
53.69%
9.9 pts better
|
Numerator 304 · Denominator 478 |
| Discharge mobility score | 60.67% |
50.94%
9.7 pts better
|
Numerator 290 · Denominator 478 |
| Pressure ulcers or injuries, new or worsened | 1.93% |
2.29%
0.4 pts better
|
Numerator 11 · Denominator 571 · Adjusted rate 2.71% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 238 · Observed rate 5.46% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 5.43% |
8.2%
2.8 pts worse
|
Numerator 12 · Denominator 221 |
| Staff flu vaccination coverage | 48.85% |
42%
6.9 pts better
|
Numerator 106 · Denominator 217 |
| Discharge function score | 73.22% |
56.45%
16.8 pts better
|
Numerator 350 · Denominator 478 |
| Transfer of health information to provider | 99.49% |
95.95%
3.5 pts better
|
Numerator 390 · Denominator 392 |
| Transfer of health information to patient | 98.7% |
96.28%
2.4 pts better
|
Numerator 152 · Denominator 154 |
| Resident COVID-19 vaccinations up to date | 55.37% |
25.2%
30.2 pts better
|
Numerator 165 · Denominator 298 |
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 · 4Q avg 100.0% |
| 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 · 4Q avg 9.1% · 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 · 4Q avg 0.0% |
| 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 · 4Q avg 2.8% · Used in QM five-star |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 9.5% · Used in QM five-star |
| 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 · Q1 94.8% · Q2 97.9% · Q3 99.3% · Q4 96.6% · 4Q avg 97.2% |
| 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 · Adjusted 17.7% · Observed 17.1% · Expected 10.8% · Used in QM five-star |
| 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 · Q1 1.3% · Q2 1.5% · Q3 2.6% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| 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 · 4Q avg 95.3% |
| 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 18.7% · Expected 20.8% · Used in QM five-star |
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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