Benedictine Health Center
BENEDICTINE HEALTH CENTER in DULUTH, MN — inspection on May 27, 2026.
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
that information should be written in a progress note. On 5/27/26 at 1:07 p.m., a telephone call was
wheelchair so they thought adding Tubigrips would be helpful for the increased swelling. RN-C was
RN-C explained the prompt to notify the provider was typically done off their weight status and not specifically for just increased edema. RN-C stated any notification to the provider would have been documented in the progress notes and expressed they did not recall placing a note for the physician or calling them on 5/7/26. RN-C reiterated they just felt the edema was from him sitting often and thought, Let's see how these [Tubigrips] work the next day or so. RN-C stated if R1's weight had been more drastically elevated along with the edema; it would have prompted an immediate telephone call to the provider. On 5/27/26 at 1:41 p.m., nurse practitioner (NP)-A stated they worked for the service R1 had been under while at the care center, however, they had not personally seen him so could not answer specific questions about his care. NP-A stated R1 remained in the hospital and discussed the current standard-of-care for heart failure is to do a daily weight and place the patient on a low sodium diet. NP-A stated it would be appropriate to update the provider at the first sign of increased swelling or edema as that was an indication something is not right. On 5/27/26 at 2:36 p.m., the director of nursing (DON) and registered nurse unit manager (RN)-B were interviewed. DON stated all nurses were aware to complete a daily check of edema for a patient with heart failure but, in general, edema was not specifically tracked in the medical record. If a nurse noticed increased swelling in the legs, then the nurse should review the previous charting to determine if the edema was more or less than previous shifts. RN-B explained a Tubigrip was like a sleeve and were able to be placed with a simple nursing order. DON verified the application of Tubigrips would be considered a form of treatment and felt the nurses could update the provider even simply as placing a note in their folder for the next rounds if the physician was scheduled to be there soon.
However, if they were needed to be used for several days in a row, then a telephone call to the provider would be appropriate. RN-B stated they felt immediate notification to the provider would only be considered for emergent items or updates. DON and RN-B verified there was nothing recorded in the medical record to demonstrate the medical provider was contacted on 5/7/26 when the edema was identified as worse and a new form of treatment was started by the nurse. RN-B stated they felt any increase of edema should be relayed to the provider and added going from a ?trace' to 2-3+ of edema in a few days period was on paper a significant increase. A facility Change in Condition, Resident Examination and Evaluation policy, dated 11/2025, identified a resident examination and evaluation would be completed upon admission, with a change in physical function, or with an acute change of condition.
The policy added, When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and [will] notify the resident/resident representative. A procedure was listed which directed to contact the medical provider for abnormalities including changes in physical status from baseline and a need to alter treatment significantly.
The notification was to be recorded in the medical record.
However, the policy lacked any definitions on what was considered a need to alter treatment significantly or what the facility defined as ?immediately.'
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.