Ecumen Duluth the Shores.
Ecumen Duluth the Shores is Grade C−, ranked in the bottom 48% of Minnesota memory care with 1 MDH citation on record; last inspected Jul 2025.
A large home, reviewed on public record.
Ranked against 142 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Ecumen Duluth the Shores has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiencie on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Ecumen Duluth the Shores's record and state requirements.
Minnesota Department of Health records show zero deficiencies across three inspection reports, with the most recent inspection on July 30, 2025 — can you walk us through how the community maintains compliance with Minn. Stat. ch. 144G dementia care requirements, and what internal audits or quality checks you use between state visits?
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One complaint was filed with MDH during the inspection period on record — can you describe the nature of that complaint, whether it was substantiated, and what steps the facility took in response?
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The license designates this as an Assisted Living Facility with Dementia Care under chapter 144G — can you provide a copy of your written dementia care program and explain how staff competency in dementia care is documented and verified?
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Every MDH visit, verbatim.
2 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-07-30Annual Compliance VisitNo findings
Plain-language summary
A routine inspection of this facility on September 16, 2025 found a violation of the infection control program requirement under Minnesota law, and the facility was assessed a $500 fine for this violation. The facility must document the steps it took to correct the infection control deficiency and implement changes to prevent future noncompliance. The facility has the right to request reconsideration or a hearing regarding the correction order and fine within 15 business days of receiving this notice.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Ecumen Duluth The Shores September 16, 2025 Page 2 § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St - 0 - 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Ecumen Duluth The Shores September 16, 2025 Page 3 To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. INFORMAL CONFERENCE In accordance with Minn. Stat. § 144A.475, Subd. 8 OR Minn. Stat. § 144G.20, Subd. 20, the Commissioner of Health is authorized to hold a conference to exchange information, clarify issues, or resolve issues. The Department of Health staff would like to schedule a conference call with Ecumen Duluth The Shores. Please contact Jessie Chenze at 218-332-5175 on or before September 19 2025, to schedule the conference call. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: Jessie.Chenze@state.mn.us Telephone: 218-332-5175 Fax: 1-866-890-9290 CLN PRINTED: 09/16/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30492 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4000 LONDON ROAD ECUMEN DULUTH THE SHORES DULUTH, MN 55804 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 *****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL30492016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On July 28, 2025, through July 30, 2025, the STATES,"PROVIDER'S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 65 residents; 50 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 100 144G.10 Subdivision 1 License required 0 100 SS=F (a)(1) Beginning August 1, 2021, no assisted LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 68S111 If continuation sheet 1 of 37 PRINTED: 09/16/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.
2024-05-14Complaint Investigation1 · Substantiated Finding
Plain-language summary
A Minnesota Department of Health complaint investigation substantiated that a staff member neglected a resident by failing to complete two required safety checks during her shift; the resident was found on the bathroom floor after approximately 12 hours with injuries from a fall, was hospitalized with acute kidney failure caused by prolonged pressure on his muscles, and died 10 days after discharge. The resident's care plan required three safety checks daily to monitor his well-being, and facility records confirmed the two checks were not completed on the day of the fall. The staff member was determined to be individually responsible for the maltreatment.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, individual responsibility N O Nature of Investigation: C The Minnesota Department of HealtEh investigated an allegation of maltreatment, in accordance R with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, R and to evaluate compliance with applicable licensing standards for the provider type. O F Initial Investigation Allegation(s): T The alleged perpetrator (AP), a facility staff member, neglected the resident when safety checks S E were not completed and the resident was found on the floor in his bathroom with wounds to U his head, and legs. Q E InvestigaRtive Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The AP failed to complete two safety checks during the shift to ensure the resident was safe. The resident was found on the floor after approximately 12 hours and was admitted to the hospital with injuries. The resident passed away. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family member and the AP. The investigation included review of the resident records, death record, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed current staff and resident interactions. The resident resided in an assisted living facility. The resident’s diagnoses included hypertension and chronic kidney disease. The resident’s service plan included safety checks three times a day at 8:00 a.m., noon, and 7:00 p.m. The resident was independent with transfers, walking, dressing, and bathing. A facility incident report indicated one day the resident was found at 7:30 p.m. kneeling on the D bathroom floor unable to call for help with wounds to his legs and open areas on both knees. E The incident report indicated the resident thought he had fallen on the floor bVetween 7:00 or I 8:00 a.m. The resident was transported to the hospital via ambulance. E C E Hospital records indicated the resident’s diagnoses included acute (severe) kidney failure R because of rhabdomyolysis (breakdown of muscle due to injury, which if not treated N immediately can lead to kidney damage), which occurred because of the fall and being on the O floor for a prolonged period of time. The resident had swelling, open areas, and blisters to both I T his legs. The resident also had bruising and scraped open areas to his forehead. During the 10 A R days at the hospital, the resident’s kidney function continued to worsen. The family chose E comfort care and the resident transferred to a facility that specialized in hospice cares. D I S The resident death record indicated the resident’s cause of death was acute kidney failure and N traumatic rhabdomyolysis. The resident pOassed away 10 days after being discharged from the C hospital. E R During an interview, unlicensed personnel stated the resident was independent with cares, R however, the resident had an evening safety check scheduled. The unlicensed personnel stated O that evening she went to complete the resident’s safety check, knocked on the resident’s F apartment door however, the resident did not answer like he usually did. The unlicensed T S personnel let herself into the resident’s room, and upon entering, found the resident in a E kneeling position leaning forward on the bathroom floor with no clothes on. The resident stated U he had fallen Qgetting out of the shower at approximately 8:00 a.m. The unlicensed personnel E called for assistance and remained the resident, while trying to keep him awake. The resident R had sores on his legs. Emergency services came and took the resident to the hospital. During an interview, nursing leadership stated, the unlicensed personnel had an electronic tablet with the resident’s plan care for review. The unlicensed personnel signed off when the resident services were completed. The day the resident fell, the resident had three scheduled safety checks. Leadership stated through the facility investigation, it was determined two of the resident’s safety checks were not completed by the AP. During an interview, the AP stated she was responsible for checking on the resident the day he had fallen. The AP stated the resident was independent with cares but needed two safety checks on her shift. The AP provided no additional pertinent information on the lack of completing safety checks on the resident. During an interview, the resident’s family member stated the resident was independent with cares and had three safety checks schedule to ensure the resident was okay. After his fall, the resident passed away 20 days later. In conclusion, the Minnesota Department of Health determined neglect was substantiated. D Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. E “Substantiated” means a preponderance of evidence shows that an act that meets the V I definition of maltreatment occurred. E C E Neglect: Minnesota Statutes, section 626.5572, subdivision 17 R “Neglect” means neglect by a caregiver or self-neglect. N (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult O with care or services, including but not limited to, food, clothing, shelter, health care, or I T supervision which is: A R (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental E health or safety, considering the physical and mental capacity or dysfunction of the vulnerable D adult; and I S (2) which is not the result of an accident or therapeutic conduct. N O C Vulnerable Adult interviewed: No. The resident was deceased. E Family/Responsible Party interviewed: Yes. R Alleged Perpetrator interviewed: Yes. R O Action taken by facility: F Resident was transported to the hospital and the AP was placed on leave during investigation. T The facility initiated aSdditional resident checks at mealtimes. The AP is no longer employed by E the facility. U Q Action taken by the Minnesota Department of Health: E R The facility was issued a correction order regarding the vulnerable adult’s right to be free from maltreatment. You may also call 651-201-4200 to receive a copy via mail or email. The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities St. Louis County Attorney Duluth City Attorney Duluth Police Department D E V I E C E R N O I T A R E D I S N O C E R R O F T S E U Q E R PRINTED: 05/15/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30492 04/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4000 LONDON ROAD ECUMEN DULUTH THE SHORES DULUTH, MN 55804 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 D E ******ATTENTION****** Minnesota Department of Health is V documenting the State Correction Orders I ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have E ORDER been assigned to CMinnesota State Statutes for Assisted Living Facilities. The E In accordance with Minnesota Statutes, section assigned tagR number appears in the far 144G.08 to 144G.95, these correction orders are left column entitled "ID Prefix Tag." The N issued pursuant to a complaint investigation. state Statute number and the O corresponding text of the state Statute out I Determination of whether a violation is corrected of Tcompliance is listed in the "Summary requires compliance with all requirements AStatement of Deficiencies" column. This R provided at the statute number indicated below.
1 older inspection from 2022 are not shown in the free view.
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