Benedictine Health Center
Duluth, Minnesota · CCN 245236
30 surveys since 2011, 13 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 119
- Surveys
- 30
- Harm or worse
- 13
- Immediate jeopardy
- 5
Findings at the most serious level CMS records. 1 of these were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 96
- Ownership
- Non profit - Church related
- Chain
- BENEDICTINE HEALTH SYSTEM
- County
- St. Louis
- Medicare-certified since
- 1980
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 4
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 52 not-for-profit facilities of 66–99 beds in Minnesota.
Last survey on record
May 27, 2026
166 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.94 | 4.39 |
| Registered-nurse hours per resident day | 0.80 | — |
| Annual nurse turnover | 51.8% | 37.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Abuse icon
- Flagged by CMS on Care Compare
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J15.3% | K15.3% | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1368.4% | E210.5% | F15.3% |
| No harm, potential for minimal | A— | B— | C15.3% |
Most frequently cited here
In CMS’s current monthly file.
- F8803×
Provide and implement an infection prevention and control program.
- F5501×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5611×
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- F5801×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F5831×
Keep residents' personal and medical records private and confidential.
In the surveyor’s words
From the most serious findings on record at Benedictine Health Center, in the surveyor’s own words.
- Immediate jeopardy, patternF880Dec 19, 2025
Based on observation, interview, and document review, the facility failed to ensure infection control interventions were implemented during an outbreak of SARS-CoV-2 (COVID), according to nationally recognized standards of practice such as Centers for Disease Control and Prevention (CDC) guidelines, including contact tracing and testing of staff and residents per guidelines. In addition, the facility staff failed to utilize proper personal protective equipment (PPE) while caring for COVID-positive residents and ensure that equipment was properly sanitized following use in a COVID-positive resident room. […]
- Immediate jeopardy, isolatedF600Nov 25, 2025
Based on interview and document review, the facility failed to ensure 1 of 1 resident (R1) was free from sexual abuse when nursing assistant (NA)-A entered R1's room with his genitals exposed to R1 and proceeded to hold R1's hand while holding his genitals in his other hand. This had the potential to result in serious psychosocial harm for R1.The IJ began on 10/22/25, at approximately 5:00 a.m., when NA-A entered R1's room and sexually abused R1. NA-A exposed his genitals to R1 through his unzipped pants and held R1's hand with one hand while holding his genitals in his other hand. The administrator and the director of nursing (DON) were informed of the IJ on 10/29/25, at 3:36 p.m. […]
- Immediate jeopardy, isolatedF600Jun 1, 2022
Based on interview and document review, the facility failed to ensure 1 of 1 residents (R1) was free from abuse when nursing assitant (NA)-A called R1 lazy and gestured his fists at R1 in a threatening manner. The IJ began on 5/26/22, at approximately 5:00 a.m. when indicated nursing assistant (NA)-A was assisting R1 to boost in bed. R1 was uncooperative and NA-A called R1 lazy. R1 responded loudly that he was not lazy, and shook his fist at NA-A. NA-A subsequently raised and shook his fist at R1 and yelled back at him. No actual physical contact was made other than appropriate boost in bed with NA-B assisting. The administrator and the director of nursing (DON) were informed of the IJ on 6/1/22, at 2:15 p.m. […]
- Immediate jeopardy, isolatedF678Jun 21, 2021
Based on interview and document review, the facility failed to ensure a system to identify a resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) situation placing the resident at risk for death in the event his heart stopped beating, and his breathing ceased. The IJ began on [DATE], when R45 requested a change from a Do Not Resuscitate (DNR status, if a person's heart stopped beating a natural death would be allowed to occur) code status to a full code status (full code status, if a person's heart stopped beating CPR would be initiated). A POLST was filled out on [DATE], and given to the health unit coordinator (HUC)-C. HUC-C made a copy and gave it to the nurse manager, registered nurse (RN)-D. […]
- Actual harm, isolatedF689Oct 12, 2022
Based on interview and document review, the facility failed to follow care plan interventions of tilting wheelchair when not eating or in activities to prevent a fall for 1 of 3 residents (R1) reviewed for accidents. This practice resulted in harm when R1 was left unattended sitting upright in her wheelchair resulting in a fall, R1 sustained a injury to her forehead and required sutures as a result of the fall. Finding Include: R1's Face Sheet printed [DATE], indicated R1's diagnoses included cerebral atherosclerosis, [CONDITION(S)] with behavioral disturbances and peripheral vascular disease. […]
Read 31 findings in full →The most serious and the most recent: 31 of 119 on record.
Every survey on record
FindingsAt actual harm or above
- May 27, 2026Complaint1 finding
- Dec 19, 2025Standard10 findings · 1 harm
- Nov 25, 2025Complaint1 finding · 1 harm
- May 15, 2025Complaint1 finding
- Dec 20, 2023Complaint1 finding
- Oct 19, 2023Standard5 findings
- Jun 2, 2023Complaint1 finding
- Oct 12, 2022Complaint1 finding · 1 harm
Show the 22 earlier surveys
- Oct 4, 2022Complaint2 findings · 1 harm
- Aug 25, 2022Standard and complaint8 findings
- Jun 1, 2022Complaint2 findings · 1 harm
- Mar 8, 2022Complaint1 finding · 1 harm
- Dec 3, 2021Complaint1 finding
- Aug 26, 2021Complaint1 finding
- Jun 21, 2021Standard14 findings · 2 harm
- Apr 8, 2021Complaint2 findings
- Jan 6, 2021Complaint2 findings
- Oct 26, 2020Complaint1 finding · 1 harm
- Oct 16, 2020Infection control1 finding · 1 harm
- Apr 7, 2020Infection control1 finding
- Jun 13, 2019Standard and complaint7 findings · 1 harm
- Apr 12, 2018Standard6 findings
- Jun 29, 2017Standard6 findings
- May 26, 2016Standard8 findings
- Jun 25, 2015Standard1 finding
- May 22, 2014Standard4 findings
- Mar 14, 2013Standard13 findings
- Jun 15, 2012—9 findings · 1 harm
- Feb 14, 2012—4 findings · 1 harm
- May 5, 2011—4 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction