Benedictine Health Center
Benedictine Health Center in DULUTH, MN — inspection on November 25, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
interviewed.
During an interview on 10:29 a.m., SSD stated LPN-A, RN-A and the SSD went into R1's room to talk about what needed to be reported. RN-A asked R1 what was wrong and R1 spelled out the word zipper. R1 reported she had been inappropriately touched by NA-A during cares. SSD stated 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. 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. 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 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 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 R1's hand.
During an interview on 10/30/25 at 8:30 a.m., NA-A stated he had entered R1's room on 10/22/25 at approximately 5:15 a.m.
His genitals were exposed to R1 outside his pants when entering the room. NA-A then proceeded to hold his genitals on one hand while grabbing R1's hand with NA-A's empty hand. NA-A did not touch his genitals with 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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