Benedictine Health Center
935 Kenwood Avenue · Duluth, MN · 55811 · 2185228900
96 certified beds Non profit - Church related Chain: Benedictine Health System
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.98 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.91 | 0.55–0.75 |
| Weekend hours / resident-day | 3.43 | ≈ weekday level |
| Nursing turnover / year | 55% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (19 in the current record)
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Immediate jeopardy · K December 19, 2025
Provide and implement an infection prevention and control program.
Corrected January 20, 2026 · Infection Control
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Potential for harm · D December 19, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 20, 2026 · Resident Rights
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Potential for harm · D December 19, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected January 20, 2026 · Resident Rights
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Potential for harm · D December 19, 2025
Keep residents' personal and medical records private and confidential.
Corrected January 20, 2026 · Resident Rights
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Potential for harm · D December 19, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected January 20, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 19, 2025
Provide care by qualified persons according to each resident's written plan of care.
Corrected January 20, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 19, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 20, 2026 · Quality of Life and Care
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Potential for harm · D December 19, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 20, 2026 · Quality of Life and Care
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Potential for harm · E December 19, 2025
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 January 20, 2026 · Pharmacy Service
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No harm found · C December 19, 2025
Post nurse staffing information every day.
Corrected January 20, 2026 · Nursing and Physician Services
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Immediate jeopardy · J November 25, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Past Non-Compliance · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 15, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 20, 2023 · found via complaint
Provide and implement an infection prevention and control program.
Corrected January 10, 2024 · Infection Control
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Potential for harm · D October 19, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 22, 2023 · Quality of Life and Care
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Potential for harm · D October 19, 2023
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 November 22, 2023 · Quality of Life and Care
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Potential for harm · D October 19, 2023
Provide enough food/fluids to maintain a resident's health.
Corrected November 22, 2023 · Quality of Life and Care
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Potential for harm · F October 19, 2023
Provide and implement an infection prevention and control program.
Corrected November 22, 2023 · Infection Control
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Potential for harm · E October 19, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected November 22, 2023 · Infection Control
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Potential for harm · D June 2, 2023 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 5, 2023 · Resident Rights
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 245236 · certified since November 17, 1980. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.