Benedictine Health Center
935 Kenwood Avenue, Duluth, MN 55811
Benedictine Health Center is a nursing home in Duluth, Minnesota. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (218) 522-8900
- Last standard health inspection
- December 19, 2025 (10 months ago)
- Certified beds
- 96
- Residents per day, on average
- 91
- Ownership type
- Non profit - Church related
- Legal business name
- Benedictine Health Center
- Chain
- Benedictine Health System
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Minnesota average (19 vs 23).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
1 citation
Health inspection on May 27, 2026
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 15, 2026.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
10 citations
Health inspection on December 19, 2025
CMS lists this as a standard inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0880. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 20, 2026.
CMS has cited this home for F0880 3 times since 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 20, 2026.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 20, 2026.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on January 20, 2026.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on January 20, 2026.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on January 20, 2026.
Citation F0659. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care by qualified persons according to each resident's written plan of care.
CMS lists it as corrected on January 20, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on January 20, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 20, 2026.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on January 20, 2026.
11 citations
Fire safety inspection on December 19, 2025
CMS lists this as a standard inspection.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on January 20, 2026.
CMS has cited this home for K0372 2 times since 2024.
Citation K0541. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on January 20, 2026.
CMS has cited this home for K0541 2 times since 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 20, 2026.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 20, 2026.
CMS has cited this home for K0920 2 times since 2024.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on January 20, 2026.
CMS has cited this home for K0223 2 times since 2024.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on January 20, 2026.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 20, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on January 20, 2026.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on January 20, 2026.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on January 20, 2026.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on January 20, 2026.
CMS has cited this home for K0761 2 times since 2024.
1 citation
Health inspection on November 25, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on May 15, 2025
CMS lists this as a complaint inspection.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on May 30, 2025.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
12 citations
Fire safety inspection on November 7, 2024
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 25, 2024.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on November 25, 2024.
Citation K0541. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on November 25, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on November 25, 2024.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 27, 2024.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on November 27, 2024.
Citation K0291. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on November 25, 2024.
Citation K0753. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on November 25, 2024.
Citation K0781. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on November 15, 2024.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on November 25, 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on November 25, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 25, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on December 20, 2023
CMS lists this as a complaint inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 10, 2024.
5 citations
Health inspection on October 19, 2023
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 22, 2023.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on November 22, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 22, 2023.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 22, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on November 22, 2023.
4 citations
Fire safety inspection on October 19, 2023
CMS lists this as a standard inspection.
Citation K0225. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on November 10, 2023.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 10, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 10, 2023.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on November 22, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BENEDICTINE HEALTH SYSTEMOperational/managerial control · not applicable · since 09/05/1985
- CARLEY, GERALDOperational/managerial control · not applicable · since 01/03/2018
Questions
When was Benedictine Health Center last inspected?
CMS lists December 19, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Benedictine Health Center have?
CMS lists 19 health citations since October 19, 2023. CMS also calls these deficiencies.
Has Benedictine Health Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Benedictine Health Center?
Its CMS overall star rating is 1 of 5.
Is Benedictine Health Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.