Safety Report: Benedictine Health Center

Duluth, Minnesota · Based on official CMS inspection records as of October 1, 2026.

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How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★
Health inspections★★★★★
Staffing★★★★★
Quality measures★★★★★
Long-stay quality★★★★★
Short-stay quality★★★★★

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

2Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
1Requirements cited on more than one inspection
K
Government finding: Provide and implement an infection prevention and control program.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected more than a very small number of residents, or happened repeatedly. Inspection of December 19, 2025. Facility reported correction by January 20, 2026.
Infection Control Deficiencies · Tag F880
J
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of November 25, 2025, during a complaint investigation.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600

Citations by topic

3Abuse, neglect & exploitation
4Infection control
1Medications & pharmacy
1Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

More citations in the most recent cycle (12) than in the cycle before (1).

Two cycles ago
none serious
Prior cycle
none serious
Most recent cycle
2 serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

RequirementTimes citedInspection dates
Provide and implement an infection prevention and control program. (F880)3December 19, 2025; December 20, 2023; October 19, 2023

Fines and enforcement

No federal fines or payment denials in the last three years.

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

19 citations across 6 inspection dates.

May 27, 2026 — 1 citation · complaint investigation
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected June 15, 2026
December 19, 2025 — 10 citations (includes serious)
K
Provide and implement an infection prevention and control program.
Immediate jeopardy to resident health or safety · Pattern · Infection Control Deficiencies · F880 · corrected January 20, 2026
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected January 20, 2026
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected January 20, 2026
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected January 20, 2026
D
Provide care by qualified persons according to each resident's written plan of care.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F659 · corrected January 20, 2026
D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F605 · corrected January 20, 2026
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected January 20, 2026
D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F561 · corrected January 20, 2026
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected January 20, 2026
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · corrected January 20, 2026
November 25, 2025 — 1 citation (includes serious) · complaint investigation
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint
May 15, 2025 — 1 citation · complaint investigation
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected May 30, 2025
December 20, 2023 — 1 citation · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected January 10, 2024
October 19, 2023 — 5 citations
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected November 22, 2023
E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F883 · corrected November 22, 2023
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected November 22, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected November 22, 2023
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected November 22, 2023

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare

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