Benedictine Health Center: Sexual Abuse by Aide - MN
That word, communicated letter by letter, was how a resident at Benedictine Health Center reported that a nursing aide had entered her room before dawn on October 22, 2025, exposed his genitals, and grabbed her hand.
The incident triggered a federal finding of immediate jeopardy, the most serious classification inspectors can assign, indicating that a facility's failures placed residents in immediate risk of serious harm or death. Federal inspection records obtained by NursingHomeNews.org describe what the resident reported, what the aide later admitted, and what cameras confirmed.
The aide, identified in inspection records as NA-A, entered the resident's room at approximately 5:15 a.m. His genitals were outside his unzipped pants when he walked in. He then held his genitals in one hand while reaching out to grab the resident's hand with the other.
The resident, identified only as R1, told the facility's Social Services Director that NA-A had physically moved her hand to make contact with his genitals. She reported that he had used her hand to touch and perform sexual acts with his genitalia. She was tearful throughout the entire interview, according to inspection records.
NA-A's account differed on one point. He told investigators he had not touched his genitals with the resident's hand. He confirmed everything else: that he had entered her room, that his genitals were exposed outside his pants, and that he had grabbed her hand while holding himself with the other.
The Director of Nursing confirmed that camera footage placed NA-A in the resident's room at 5:15 a.m. on October 22. Staff who were asked whether anyone had accompanied NA-A into the room all said no. The cameras said otherwise.
The Social Services Director described the moment staff first learned something had happened. An LPN, an RN, and the Social Services Director went into the resident's room together. The RN asked the resident what was wrong. The resident spelled out the word zipper.
What followed was a conversation that required patience and attention, because every word the resident communicated had to be spelled out, one letter at a time. By the end of it, staff understood what had happened in that room before sunrise.
The facility's abuse prevention policy, last updated in July 2022, defined sexual abuse as non-consensual sexual contact of any type with a resident. What the resident described, and what the aide partially confirmed, fell squarely within that definition.
Federal inspectors classified the violation under F0600, the regulation governing protection from abuse, neglect, and exploitation. The immediate jeopardy designation reflects a determination that the facility's failure to prevent the abuse placed residents at risk of serious harm.
The inspection records note that the immediate jeopardy was cited as past noncompliance, meaning the facility had already taken corrective action by the time inspectors made their finding. NA-A was suspended on October 22, the same day the incident occurred, and later resigned. The facility conducted an investigation that included interviews with other residents and staff. No additional incidents of abuse were found. All staff received retraining on abuse prevention, and the facility reviewed its abuse policy as part of the investigation.
The immediate jeopardy was formally removed on October 22, the date of the suspension.
That timeline, the abuse occurring and the immediate jeopardy both beginning and ending on the same calendar date, reflects how the federal classification system can work when a facility moves quickly. The designation still stands in the inspection record. The finding is permanent.
What the record does not resolve is how a nursing aide walked into a vulnerable resident's room in the early morning hours with his pants unzipped. The inspection narrative does not describe what NA-A was doing in the room at 5:15 a.m., whether he had a legitimate reason to be there, or what he said when asked. It does not describe whether other staff were on the floor at that hour, whether call bells were going unanswered elsewhere, or what the resident's condition was in the moments before and after.
It describes what she spelled out. It describes what the cameras showed. It describes a woman who was tearful throughout the entire interview.
Benedictine Health Center is a long-term care facility in Duluth. The complaint inspection that produced this finding was conducted in late October and November 2025.
The resident who spelled out the word zipper communicated something that many people in her situation could not have communicated at all. She found a way to say what happened to her. Whether the systems around her, the staffing, the supervision, the early morning routines on that floor, were adequate to prevent it from happening in the first place is a question the inspection record raises but does not answer.
She was tearful throughout the entire interview. The record says that once, in a single sentence, and then moves on.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benedictine Health Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
Benedictine Health Center in DULUTH, MN was cited for abuse-related violations during a health inspection on November 25, 2025.
Federal inspection records obtained by NursingHomeNews.org describe what the resident reported, what the aide later admitted, and what cameras confirmed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.