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Nursing HomeMedicaid Investigative

Benedictine Health Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

935 Kenwood Avenue, Kenwood · Duluth, MN 5581196 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
5.0/5

based on 4 Google reviews

Benedictine Health Center Nursing Home in Duluth, MN — Street View
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7/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Above-median deficiencies (12 vs median 6.5)
  • High staff turnover (60%)
  • High RN turnover (53%)

Bottom 25% in MN · Meets national RN staffing standard · Worst in BENEDICTINE HEALTH SYSTEM chain · No penalties on record · Abuse citation

Source: Medicare data

What this means for your family

It is difficult to assess the quality of care due to a lack of descriptive detail in recent reviews. While the staff is praised in the available text, families should request a tour and speak with current residents to verify care standards.

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.91hrs
OK
Registered nurses for medical care
Total Nursing
3.98hrs
97%
All nurses + aides combined
Staff Turnover
55%
Lower is better (< 30% = good)
RN Turnover
59%
Lower is better (< 30% = good)

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

8

measures

Worse Than Avg

5

measures

Mixed Results

4

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility32.4%
Worse than Avg
Here
32.4%
US
15.3%
MN
21.4%
St. louis
16.1%
😔

Residents with depression symptoms

↓ Lower is better
This Facility4.3%
Better than Avg
Here
4.3%
US
12.1%
MN
4.3%
St. louis
19.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility92.8%
Mixed vs Avgs
Here
92.8%
US
93.4%
MN
97.3%
St. louis
83.1%
🩹

Residents with pressure sores (bedsores)

↓ Lower is better
This Facility12.1%
Worse than Avg
Here
12.1%
US
4.9%
MN
5.3%
St. louis
5.8%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility23.0%
Mixed vs Avgs
Here
23.0%
US
19.4%
MN
24.5%
St. louis
18.1%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility17.3%
Mixed vs Avgs
Here
17.3%
US
19.5%
MN
12.5%
St. louis
16.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility92.0%
Better than Avg
Here
92.0%
US
81.8%
MN
88.3%
St. louis
63.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility92.0%
Better than Avg
Here
92.0%
US
79.7%
MN
82.7%
St. louis
64.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.3%
Better than Avg
Here
1.3%
US
1.6%
MN
1.8%
St. louis
1.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

12deficiencies
Above state avg (8.0)
4 complaint-triggered

Families have filed complaints leading to four serious deficiencies, including concerns about resident protection and abuse reporting. The facility struggles with recurring fire safety issues, infection control problems, and resident rights violations that persist across multiple surveys from 2023 to 2025. While the provider reports correcting these issues, the pattern of repeated problems in critical safety areas warrants careful consideration during visits.

Dec 19, 2025Routine
21
0880Immediate jeopardy · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0541Potential for harm · WidespreadCorrected

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0223Potential for harm · IsolatedCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0521Potential for harm · IsolatedCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0761Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0561Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0605Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0659Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0732Minimal · Widespread

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Nov 25, 2025Complaint
1
0600Immediate jeopardy · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

May 15, 2025Complaint
1
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Nov 7, 2024Routine
12
0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0541Potential for harm · WidespreadCorrected

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0291Potential for harm · PatternCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0753Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

0781Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

0223Potential for harm · IsolatedCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Dec 20, 2023Complaint
1
0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Oct 19, 2023Routine
9
0225Potential for harm · WidespreadCorrected

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

0321Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0883Potential for harm · PatternCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0351Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Benedictine Health Center

Organization Type

nonprofit

Chain Affiliation

Chain Name

Benedictine Health System

Chain Size

23 facilities nationwide

Chain avg rating: 2.9/5 · Rank 21 of 22 (Worst)

Ownership & Management

Key personnel

Pattock, BrianContracted Managing EmployeeBowe, TiaOfficer / DirectorEckes, LoisOfficer / DirectorFedora, ToddOfficer / DirectorHansen, GregOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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