Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benedictine Health Center during CMS and state inspections, most recent first.
Delayed Provider Notification for Worsening Edema: A resident with CHF developed worsening BLE edema, and nursing staff started Tubigrips and elevation without documenting timely provider notification. The resident’s edema increased from trace to 2-3+, while daily weights were monitored and the provider later noted swelling on exam. Interviews showed staff relied mainly on weight thresholds for notification, and the record did not show the provider was contacted when the new treatment was initiated.
Infection control failures occurred during a COVID outbreak when the facility did not consistently use contact tracing or serial testing for exposed residents and staff, and staff were observed entering COVID-positive rooms without the required N95s. Reusable equipment was also taken from a COVID-positive room without being sanitized, and kitchen staff were observed without source control masks. The report also found a resident with an indwelling catheter had the drainage bag left directly on the floor, with the spout contacting the floor.
Improperly labeled and expired medications and supplies were found in multiple med rooms and med carts. Staff identified an expired Mucinex box during a med pass, and reviews found expired insulin syringes, inhalers, creams, nitroglycerin, lab tubes, IV supplies, and discharged resident medications. Several opened items, including insulin pens and an inhaler, were not dated as required by staff practice.
A resident with Alzheimer's disease, dementia, and diabetes mellitus was observed during dining while a TMA stood next to her and assisted with eating. The resident's care information indicated she needed set up, cues, and encouragement for meals and hydration. RN-E and the DON stated staff should be seated for face-to-face contact when helping a resident eat, and the facility policy called for assistance with attention to safety, comfort, and dignity.
A resident with moderate cognitive impairment, dementia, encephalopathy, and epilepsy who was his own decision maker had medications crushed and hidden in food so he would not know they were there, despite documentation that he sometimes refused meds and staff acknowledgment that residents have the right to refuse treatment. Staff and hospice confirmed the practice was used because he would refuse if told the meds were being given. The report also found that a resident with a vision deficit was not assisted with selecting menu choices when unable to do so independently.
Failure to provide privacy during toileting and self-care: A cognitively intact resident with MS, paraplegia, bladder dysfunction, and constipation requested a privacy curtain or barrier for intermittent self-catheterization and enema use performed in bed. The care plan did not address the resident’s privacy needs, staff documented the request but no action was taken for a period of time, and observation showed the resident was visible from the doorway/hallway when the room door was open.
The facility failed to document nonpharmacological interventions and specific triggers before giving PRN psychotropic medication to a resident with dementia and behavioral concerns, and staff stated the medication was sometimes given just in case or to prevent possible behaviors later in the shift. A second resident had a PRN lorazepam order for anxiety with no stop date, and the DON verified the order lacked an end date. The care plans and MARs reviewed did not show the required behavioral detail or medication limits for the PRN psychotropic use.
Unqualified staff were involved in administering a resident’s medications. An RN crushed meds into hot cereal and placed the tray back on the cart, then an RD delivered the tray to the resident’s room while the resident was asleep and did not verify the right resident or educate on the meds. Interviews confirmed the RD and NA had no med administration training, while only TMA, LPN, and RN staff were qualified to administer meds per facility policy.
Failure to Complete Morning Oral Care: A resident with Alzheimer's disease and dementia who needed assistance with ADLs did not receive oral care during morning cares or after breakfast. Staff helped with dressing, brief change, grooming, and transport to breakfast, but no one offered to brush the resident's teeth afterward. Interviews confirmed oral care was expected as part of morning cares, though staff said limited CNA staffing made it difficult to complete all tasks.
A secure memory care unit had a back exit door that was not locking or alarming, despite a resident with severe cognitive impairment, wandering, and exit-seeking behavior being at risk for elopement. Staff notes and observations showed the resident got through the door, attempted to leave the unit, and was later seen pushing the door open without any alarm sounding. Interviews confirmed the door had been nonfunctioning for an extended period, and staff had placed a chair in front of the exit.
The facility failed to ensure the daily nursing staffing posting included the actual facility name and was updated with staffing changes. Surveyors observed a staffing report posted under a different facility name, and the DON verified that changes were not reflected on the posting for residents and visitors to see. The DON and clinical managers were also included in RN hours even though their job descriptions and the facility assessment identified them as administrative or supervisory personnel rather than direct resident care staff.
Failure to protect a vulnerable resident from sexual abuse: A cognitively intact resident with hemiplegia, dysphagia, and aphasia reported that an NA entered the room with his genitals exposed, then grabbed the resident’s hand and placed it around his genital region with skin-to-skin contact. The NA stated his genitals were outside his pants and that he held the resident’s hand while holding his own genitals in the other hand. The resident was tearful when describing the incident, and the care plan identified the resident as vulnerable to abuse.
A resident with a history of stroke, right-sided paralysis, and cognitive impairment was found with extensive bruising and swelling on her right arm. Staff observed the injury and notified the on-call nurse, but the incident was not reported to the administrator or State Agency within the required timeframe. Confusion among staff regarding reporting protocols led to a delay, despite facility policy mandating immediate notification for injuries of unknown origin involving serious bodily harm.
Delayed Provider Notification for Worsening Edema
Penalty
Summary
The facility failed to ensure the medical provider was updated in a timely manner when a resident with chronic heart failure developed worsening bilateral lower-extremity edema and the nurses initiated a new intervention, Tubigrips, to manage the swelling. The resident had been hospitalized for acute blood loss anemia and had multiple diagnoses including high blood pressure, chronic heart failure, atrial fibrillation, and diabetes mellitus. On admission to the care center, the resident had trace edema in both legs, clear lung sounds, and shortness of breath at rest, and the hospital discharge summary also noted mild pitting edema in both lower extremities and a weight of 212.1 pounds. During the stay, nursing documentation showed the resident’s edema increased to 2-3+ in both lower extremities, and the nurse wrote an order for Tubigrips and elevation of the affected extremities. Daily weights recorded at the care center ranged from 198.8 pounds to 202.8 pounds over several days. The medical provider saw the resident the next day and documented swelling of both lower extremities, but the record did not show that the provider had been contacted when the increased edema was first identified or when the new treatment was started. Interviews with nursing staff and leadership showed differing views on when provider notification was required. An LPN and the RN who documented the edema stated notification was typically based on weight gain rather than edema alone, and the RN did not recall calling the provider on the day the Tubigrips were started. The DON and RN unit manager acknowledged that the application of Tubigrips was a treatment and agreed there was nothing in the record showing the provider was contacted when the edema worsened, although they also stated edema was generally monitored daily and that increased swelling should be relayed to the provider. The facility policy required consultation with the attending provider when a significant change in status was identified or when treatment needed to be altered significantly, and required that notification be recorded in the medical record.
Infection Control Failures During COVID Outbreak and Improper Catheter Bag Placement
Penalty
Summary
The facility failed to implement infection prevention and control measures during a SARS-CoV-2 outbreak, including contact tracing, testing of exposed staff and residents, proper PPE use, and sanitizing reusable equipment after use in COVID-positive resident rooms. The report states that the immediate jeopardy began when appropriate infection control interventions were not implemented after the first positive COVID case in the facility, and that the outbreak expanded to multiple residents and staff members across units. The facility’s own COVID-19 policy required symptom- and contact-based testing, outbreak investigation testing, and repeated testing of exposed residents and staff, but staff interviews indicated testing was largely symptom-based and that documentation of contact tracing and negative tests was not maintained. The outbreak involved multiple residents and staff. Residents identified as COVID-positive included R72, R94, R65, R84, R31, R20, R41, R61, R69, R81, R13, R106, R109, R39, R64, R90, R29, R51, and R110. Three residents, R69, R72, and R94, were later hospitalized. R72, who had kidney failure with dialysis dependence, heart failure, diabetes, and a heart arrhythmia, developed respiratory symptoms after returning from dialysis and later required hospital transfer for worsening condition. R69, who had dementia, heart disease, and convulsions, developed chills, increased confusion, weakness, and falls before being transferred to the hospital. R94 tested positive and was later hospitalized with low sodium and pneumonia. Staff cases included a cook, nursing assistants, dietary aides, registered nurses, an unknown department supervisor, and a laundry aide. Observations also showed staff entering COVID-positive resident rooms without the PPE required by the isolation signage. RN-D entered R109’s room wearing a gown, gloves, eyewear, and a surgical mask instead of an N95, and NA-E entered R81’s room with similar PPE but also without an N95. The infection preventionist and DON confirmed that an N95 should have been worn in those rooms. In addition, NA-D brought a vital sign machine out of R69’s COVID-positive room and did not sanitize it afterward. The report also states that kitchen staff were observed in close proximity without source control masks in place during the outbreak period. The facility also failed to ensure proper catheter care for R5, who had an indwelling catheter for obstructive and reflux uropathy with urinary retention and was on enhanced barrier precautions. During multiple observations, R5’s catheter bag was directly on the floor at the foot of the bed, and the drainage spout was in direct contact with the floor. RN-E and the DON stated the catheter bag should not be on the floor and should be concealed in a dignity bag and positioned below the bladder.
Improperly Labeled and Expired Medications and Supplies Found in Medication Rooms and Carts
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly labeled and that expired medications and supplies were removed from medication rooms and carts. During a medication pass, a TMA pulled Mucinex for a resident and found the box had expired; the medication was removed and the resident received Mucinex from a non-expired medication card instead. The report also identified expired and improperly dated items in multiple medication carts, including an opened insulin syringe that was not dated, an insulin pen with an unreadable date, expired famotidine, a discharged resident’s inhaler, and a box of expired Mucinex. A review of the third-floor medication room found expired insulin syringes and expired blood culture bottles. The DON later confirmed two partial boxes of 100-unit insulin syringes had expired months earlier and were still stored in the medication room. On the second-floor medication room and blood draw supply area, the DON confirmed expired safety needles were present, along with expired resident-labeled IV supplies from a discharged resident, including central line dressing kits, IV positive pressure caps, PICC plus stat locks, and Guardiva dressings. The DON also reviewed the lab cart used by facility staff and a hospital for drawing labs and found approximately 25 expired lab tubes, along with additional expired green top and yellow top tubes in the supply cabinet. A separate medication cart review found additional expired resident medications and supplies, including expired insulin syringes, expired hydrochloride cream, nystatin powder, hydrocortisone creams, and an open bottle of nitroglycerin labeled to discard after a prior date. The cart also contained a partially used Ozempic pen and a glargine insulin pen that were not labeled with the date first opened. Another cart contained medications for a resident who had been discharged from the facility, along with a current resident’s inhaler that had been opened but not dated. Staff stated that inhalers, eye drops, and insulin pens should be dated when opened, and the DON stated only properly labeled, current resident, non-expired medications and supplies were expected to be stored in carts and medication rooms.
Dignified Dining Assistance
Penalty
Summary
The facility failed to ensure a dignified dining experience for 1 of 11 residents observed during a meal. R16 had diagnoses including Alzheimer's disease, dementia, and diabetes mellitus, and the MDS indicated the resident was generally understood, could understand, and was severely cognitively impaired. The resident's group sheet stated that R16 required set up with cues and encouragement for meals and hydration. During dining observation, a TMA was seen standing next to R16 while assisting her with eating. RN-E stated she would expect staff to sit in a chair next to a resident when helping with eating, and the DON verified that staff assisting a resident to eat should be seated for face-to-face contact and that it was not dignified to stand over a resident while helping with a meal. The facility policy stated residents who cannot feed themselves will be assisted with attention to safety, comfort, and dignity.
Failure to Honor Resident Refusal and Assist with Menu Choices
Penalty
Summary
The facility failed to promote resident choice and the right to refuse treatment for a resident with moderate cognitive impairment, dementia, encephalopathy, and epilepsy who was his own responsible party. The resident’s care plan identified that he was non-compliant and refused medications at times, and hospice had an order stating it was okay to hide medications in food if needed. Progress notes documented that the resident refused nighttime medications and was suspicious of hidden blueberries in his drink, while other notes stated crushed olanzapine was hidden in his coffee and that orders to crush and hide medications in food appeared to be working well. During observation, an RN was seen crushing the resident’s medications and mixing them into a bowl of hot cereal, then placing the bowl back on the food cart with other meal trays. Interviews with nursing staff and hospice staff confirmed that the medications were being hidden in food so the resident would not know they were there and would not refuse them. Staff also stated the resident had no POA and was his own decision maker, and the DON stated residents had the right to refuse care or treatment, including medication administration. The report also identified that a resident with a vision deficit was not assisted in selecting menu choices when unable to do so independently.
Failure to Provide Privacy During Toileting and Self-Care
Penalty
Summary
The facility failed to ensure adequate privacy was in place before and after a cognitively intact resident with multiple sclerosis, paraplegia, neuromuscular dysfunction of the bladder, and constipation requested privacy measures for toileting and self-care performed in bed. The resident’s care plan included a bowel toileting program and self-performed intermittent catheterization, but it did not address the resident’s privacy needs during self-care activities or bed pan use. A progress note documented that the resident requested a privacy curtain because anyone could open the door and enter the room, and the nurse noted the resident had extensive toileting needs that warranted increased privacy. During interviews, the resident stated they performed intermittent self-catheterization and used Fleets enemas while in bed, which required opening their legs wide apart, and that without a privacy curtain their bed was in full view when the door was open. The resident reported asking multiple staff members for a privacy curtain or barrier, including the nurse manager, but nothing had been done, and belongings used as a shield were not adequate. Observation confirmed the resident was viewable from the doorway/hallway when the room door was open. The administrator acknowledged the request had been discussed but had not been pursued because the resident was in a single room, and an LPN confirmed the request had been reported to the care team.
Failure to Document Nonpharmacological Interventions and PRN Psychotropic Stop Dates
Penalty
Summary
The facility failed to ensure residents were free of chemical restraints and failed to document nonpharmacological interventions before administering PRN psychotropic medications. For one resident with moderate cognitive impairment and diagnoses including dementia, encephalopathy, and epilepsy, the care plan identified psychotropic medication use and a psychosocial concern related to potential agitation or aggression, but it did not specify target behaviors to monitor or what nonpharmacological interventions to attempt before giving medication. The physician order report showed olanzapine and PRN lorazepam for anxiety/agitation, but the MAR and progress notes did not contain documentation of specific triggers or attempted nonpharmacological interventions before PRN lorazepam was administered. For that resident, progress notes showed an incident in which another resident entered the room and was struck, after which the residents were separated and a stop sign strap was placed on the doorway. Nursing interview indicated the resident was calm after the incident, but PRN lorazepam was still given later that shift "just in case" and to prevent possible behaviors later. Staff also stated that PRN psychotropic medication had at times been given before behaviors occurred to keep the resident from having possible behaviors, and that documentation of triggers and interventions was expected but not present in the record reviewed. A second resident with diagnoses including convulsion, dementia, anxiety, insomnia, pain, and depression had a PRN lorazepam order for anxiety with a start date but no end date. The consultant pharmacist report did not address the missing stop date, and the DON verified the PRN lorazepam order had no end date even though the facility expected PRN psychotropic medications to have both a start and end date. The facility policy stated PRN antipsychotic orders are limited to 14 days and cannot be renewed unless the attending provider evaluates the resident for appropriateness of the medication.
Unqualified Staff Involved in Medication Administration
Penalty
Summary
Facility staff failed to have qualified persons administer medications according to the resident’s written plan of care. The resident involved had moderate cognitive impairment on the quarterly MDS and diagnoses of dementia, encephalopathy, and epilepsy. The care plan dated 6/26/25 identified that the resident received high risk medications and directed staff to administer medications per MD order and observe for side effects of medications. During observation on 12/18/25 at 9:36 a.m., an RN was seen crushing the resident’s medications and mixing them into a bowl of hot cereal, then placing the bowl back on the food cart with the other meal trays. Later that morning, the RD delivered the resident’s tray to the room and left it on the bedside table while the resident was asleep, without waking the resident to educate on the medications or verify the right resident was receiving the right medications. Interviews with the RN, RD, NA, and DON confirmed that only TMAs, LPNs, and RNs were trained and qualified to gather and administer medications, and that the RD and NA had no medication administration training. The facility policy stated medications were to be administered by licensed nurses or trained delegated associates and according to the 6 Rights of medication administration.
Failure to Complete Morning Oral Care
Penalty
Summary
The facility failed to ensure morning cares, including oral care, were completed for a resident with Alzheimer's disease and dementia who required partial to moderate assistance with ADLs. The resident's MDS identified the need for substantial assistance with dressing and oral hygiene, and the group sheet listed substantial assistance of one for oral hygiene. The care plan identified self-deficits with bathing, grooming, and oral cares, with interventions for extensive assist of one for bathing, but it did not address oral care. During continuous observation, nursing assistants helped the resident get dressed, changed her brief, assisted her into a wheelchair, combed her hair, and brought her to breakfast. After breakfast, the resident remained in the dining room and later participated in activities, but no staff offered to take her to her room to brush her teeth after breakfast. A family member stated they did not think the resident's teeth were being brushed twice a day. The NA verified oral care was not completed during morning cares or after breakfast. Staff interviews confirmed morning cares were expected to include oral care, but staffing was limited, and the DON stated oral care was part of morning and evening cares and important to provide.
Broken Memory Care Exit Alarm
Penalty
Summary
The facility failed to ensure a locked door on the secure memory care unit had a functioning alarm to prevent residents at risk for elopement from leaving unobserved. One resident reviewed for elopement risk had diagnoses including macular degeneration, hearing loss, and cognitive communication deficit, and the MDS identified severe cognitive impairment, behaviors, wandering, and daily wanderguard use. The care plan identified cognitive loss with exit-seeking behavior, wandering toward doorways and elevators, and interventions including distraction, redirection, wanderguard use, comfort measures, and a secure memory care unit with specialized programming. Records and observations showed the resident repeatedly wandered and exit-seeked, including attempts to open stairwell doors, get on elevators, and leave the unit. A nursing note documented the resident got through the back door and that the back door alarm was broken. During observations, the back door alarm did not sound when dietary staff used the entrance/exit, and the resident was later observed pushing the back door open and getting part way out before being pulled back by the DON, with no alarm sounding. Staff interviews confirmed the back door had not been locking or alarming, that a chair had been placed in front of the exit, and that the door had reportedly not been functioning since the end of November. The administrator and executive director also verified the door was not locking and that placing furniture in front of the door was not acceptable.
Nursing Staffing Posting Did Not Show Facility Name or Accurate Direct Care Hours
Penalty
Summary
The facility failed to ensure the daily nursing staff posting included the facility name and reflected staffing changes. On 12/15/25 at 4:22 p.m., surveyors observed a staffing hours report posted for "Nursing at Duluth-SNF" with a census of 93. The posting listed nursing assistant and trained medication aide hours totaling 93.25, LPN hours totaling 32, and RN hours totaling 40. The RN section included two clinical managers, the DON, and two RNs, and the DON's hours and the clinical manager hours were included in the total hours for nursing care. During interviews on 12/18/25, the DON verified that staffing hours were posted daily but changes were not made on the posted sheet for residents and visitors to see, and that changes were noted elsewhere. The DON also verified that his hours and the clinical manager hours were included in the total worked hours for direct care, and that the actual facility name, Benedictine Living Community, was not on the posting. The HRD stated she was making the nursing schedule and did not know why the facility name was missing from the posting. She also verified that changes were not made on the posting and that the DON and clinical managers' daily responsibilities did not include direct resident care. The DON and clinical manager job descriptions identified their roles as administrative, supervisory, and leadership positions, and the annual facility assessment listed the DON and nurse managers as other nursing personnel with administrative duties.
Failure to Protect a Vulnerable Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure one cognitively intact resident with hemiplegia, dysphagia, and aphasia was free from sexual abuse when a nursing assistant entered the resident’s room with his genitals exposed through unzipped pants and held the resident’s hand while holding his genitals in the other hand. The resident’s care plan identified vulnerability to abuse, physical limitations related to stroke, and communication deficits, and also noted the resident believed sexual trauma had been experienced. The resident reported that the nursing assistant came into the room with his pants unzipped, exposed his genitals where the resident could see them, and then grabbed the resident’s hand and placed it around the genital region, with skin-to-skin contact. The resident was tearful during the interview and communicated the account using a letter board. The nursing assistant stated he entered the room to empty the catheter bag, that his genitals were outside his pants, and that he held the resident’s hand while holding his own genitals in the other hand; he denied that the resident’s hand touched his genitals. The facility’s investigation file and staff interviews documented the incident and the resident’s report of inappropriate touching.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency within the required timeframe for one resident. The resident, who had a history of stroke, right-sided paralysis, moderate cognitive impairment, and was on anticoagulant and antiplatelet medications, was found with extensive bruising and swelling on her right arm, extending from the armpit to the hand. The injury was first noted by staff in the early morning, and the resident was unable to recall any incident that could have caused the injury. Documentation showed that the injury was reported to the on-call nurse, but not to the facility administrator or the State Agency until the following day, exceeding the mandated reporting window. Staff interviews revealed confusion regarding the reporting protocol, with some staff believing the State Agency should be notified within 24 hours, while the facility's policy required immediate reporting, but not later than two hours, if the injury involved suspected abuse or resulted in serious bodily injury. The administrator confirmed she was not informed until the next morning and subsequently filed the report with the State Agency. The facility's own Abuse Prevention Plan defined injuries of unknown source and outlined the required reporting timelines, which were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aftenro Home | 0.4 mi | ★★★★★ | 17 | 0 |
| Hilltop Healthcare Rehabilitation And Skilled Nurs | 1.3 mi | ★★★★★ | 17 | 0 |
| Ecumen Lakeshore | 2.8 mi | ★★★★★ | 8 | 0 |
| Bayshore Residence And Rehabilitation Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Viewcrest Health Center | 3.5 mi | ★★★★★ | 0 | 0 |
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