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Ecumen Lakeshore

4002 London Road, Duluth, MN 55804
2186257100
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Overall CMS Rating

5.0/5

vs State Average: 3.2 stars

5.0/5

Health Inspections

vs State Average: 2.8/5

5.0/5

Staffing Level

vs State Average: 4.1/5

4.0/5

Quality Measures

vs State Average: 3.2/5

0 penalties in last 3 years
Penalties
vs State Average: 1 penalties

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Ratings Deep Dive

Score
5.0
State Average
2.8
National Average
2.8
5 Deficiencies found in last inspections
0 Penalties in last 3 years
0 Fines issued
Citation Date Description Severity
Aug 7, 2025 Ensure each resident receives an accurate assessment. D
Jun 13, 2024 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F
Sep 8, 2023 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. D
Sep 8, 2023 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. D
Sep 8, 2023 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. D
Score
5.0
State Average
4.1
National Average
2.9
1.7 RN Hours / Resident / Day
4.9 Total Nurse Hours / Resident / Day
32.3% RN Turnover Rate
Score
4.0
State Average
3.2
National Average
3.6
Long-Stay QM Rating
4.0 Short-Stay QM Rating
52.4 Avg Residents Per Day
Measure Score Type
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay
Percentage of long-stay residents who lose too much weight Long Stay
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay
Percentage of long-stay residents with a urinary tract infection Long Stay
Percentage of long-stay residents who have depressive symptoms Long Stay
Percentage of long-stay residents who were physically restrained Long Stay
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay

Ownership & Compliance

Ownership Info
5% OR GREATER DIRECT OWNERSHIP INTEREST ECUMEN
OPERATIONAL/MANAGERIAL CONTROL ALAM, MORSHED
OPERATIONAL/MANAGERIAL CONTROL KENDRICK, SHELLEY
CORPORATE DIRECTOR ALAM, MORSHED
CORPORATE DIRECTOR DADY, JAMES
CORPORATE DIRECTOR KENDRICK, SHELLEY
CORPORATE DIRECTOR KRO, LISA
CORPORATE DIRECTOR ULVESTAD, NANCY
CORPORATE OFFICER ALAM, MORSHED
CORPORATE OFFICER CERVENKA, DEBBIE
Recent Penalties

No penalty records found.

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