Benedictine Health Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
interviewed.During an interview on 10:29 a.m., SSD stated LPN-A, RN-A and the SSD went into Resident R1's room to talk about what needed to be reported. RN-A asked Resident R1 what was wrong and Resident R1 spelled out the word zipper. Resident R1 reported she had been inappropriately touched by NA-A during cares. SSD stated Resident R1 reported NA-A physically moved the hand to make contact with NA-A's genitals. NA-A was not clothed and skin to skin contact had happened. Resident R1 had also reported to SSD NA-A had used her hand to touch and perform sexual acts with his genitalia but penetration had not occurred. Resident R1 was tearful throughout the entire interview.During an interview on 10/29/25 at 12:46 p.m., the DON stated everything happened on 10/22/25 around 5:15 a.m. The incident was reported as soon as he found out about it. All staff reported they did not go in the room with NA-A, but review of the cameras confirmed NA-A had entered Resident R1's room around 5:15 a.m. on 10/22/25. The DON confirmed NA-A reported the genitals were outside his unzipped pants and that
he had held Resident R1's hand while holding his genitals outside of his pants with NA-A's other hand. NA-A reported he did not touch his genitals with Resident R1's hand.During an interview on 10/30/25 at 8:30 a.m., NA-A stated he had entered Resident R1's room on 10/22/25 at approximately 5:15 a.m. His genitals were exposed to Resident R1 outside his pants when entering the room. NA-A then proceeded to hold his genitals on one hand while grabbing Resident R1's hand with NA-A's empty hand. NA-A did not touch his genitals with Resident R1's hand.The facility's Abuse Prevention Plan last revised 7/21/22, indicated the definition of abuse included the willful infliction of unreasonable confinement, intimidation or punishment of which resulted in physical harm, pain or mental anguish. This included sexual and mental abuse. Sexual abuse was defined as the non-consensual sexual contact of any type with a resident.The past noncompliance IJ began on 10/22/25. The IJ was removed and
the deficient practice corrected on 10/22/25, when NA-A was suspended and later resigned. The facility conducted an investigation which included other resident interviews and staff interviews (no further incidents of abuse were found), and re-training was completed at that time for all staff related to abuse and was confirmed through review of education and signed attendance sheets showing all staff received training. The abuse policy was also reviewed as part of the investigation.
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Benedictine Health Center in DULUTH, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DULUTH, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Benedictine Health Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.