Ecumen Lakeshore: Data Analysis and Ratings
CMS Five Star Rating(5 out of 5):
4002 LONDON ROAD DULUTH, MN 55804
218-625-7100
Data date: April 01, 2023
The Most Important Data about Ecumen Lakeshore
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at Ecumen Lakeshore. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(5 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Improving
Total Nursing Hours Spent Per Resident Per Day: 5.56
(The national average is 3.74 )
According to our analysis, Ecumen Lakeshore is ranked #4 out of 15 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Ecumen Lakeshore.
What is this page all about?
Below is everything shred of information that we can find about Ecumen Lakeshore, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: April 01, 2023
Address: 4002 LONDON ROAD
DULUTH, MN 55804
Phone: 218-625-7100
Ranking: Ecumen Lakeshore is ranked #3 out of 11 facilities within a 10 mile radius and #4 out of 15 facilities within a 25 mile radius.
Medicare Provider Number: 245215
Participating in Medicare Since: July 01, 1977
No. of Certified Beds: 60
No. of Residents: 49
Occupancy: 81.67 % (as of 05/14/2023 )
Amount fined in recent period: $23,185.61
Complaints filed: 0
Ratings History for Ecumen Lakeshore
Review of Ecumen Lakeshore Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 5: |
| Health Inspection Rating | 3: |
| Quality Rating | 5: |
| Staffing Rating | 5: |
Inspection Scores
| Cycle 1 Score (as of May 25, 2022) | 36 |
| Cycle 2 Score (as of April 15, 2021) | 44 |
| Cycle 3 Score (as of March 20, 2019) | 68 |
| Weighted All Cycles Score | 44 |
It has been 10 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Ecumen Lakeshore including health, fire, and inspection control inspections:
| Inspection Type | Inspection Date |
|---|---|
| Fire Safety Standard | May 23, 2022 |
| Fire Safety Standard | April 13, 2021 |
| Fire Safety Standard | March 20, 2019 |
| Health Complaint | November 08, 2022 |
| Health Complaint | May 25, 2022 |
| Health Complaint | July 30, 2021 |
| Health Complaint | August 13, 2020 |
| Health Standard | May 25, 2022 |
| Health Standard | April 15, 2021 |
| Health Standard | March 20, 2019 |
| Infection Control | November 02, 2020 |
| Infection Control | August 13, 2020 |
| Infection Control | June 24, 2020 |
| Infection Control | April 16, 2020 |
Owner and Operator Information for Ecumen Lakeshore
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Managers and Directors:
- MORSHED ALAM (OPERATIONAL/MANAGERIAL CONTROL)
- MORSHED ALAM (DIRECTOR)
- MORSHED ALAM (OFFICER)
- DEBBIE CERVENKA (OFFICER)
- JAMES DADY (DIRECTOR)
- SHELLEY KENDRICK (OPERATIONAL/MANAGERIAL CONTROL)
- SHELLEY KENDRICK (DIRECTOR)
- SHELLEY KENDRICK (OFFICER)
- SHELLEY KENDRICK (MANAGING EMPLOYEE)
- LISA KRO (DIRECTOR)
- NANCY ULVESTAD (DIRECTOR)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of Ecumen Lakeshore spends MORE time on average with its residents than the state average for total nursing homes spent per resident and MORE time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 2.07 | 1.03 / 0.65 |
| Case Mix | 0.47 | 0.31 / 0.39 |
| Adjusted | 1.70 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 0.56 | 0.67 / 0.88 |
| Case Mix | 0.81 | NA / NA |
| Adjusted | 0.51 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 2.92 | 2.34 / 2.21 |
| Case Mix | 2.05 | NA / NA |
| Adjusted | 2.91 | NA / NA |
| Total Licensed Staff | ||
| Hours | 2.64 | 1.70 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.38 | 0.07 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 5.56 | 4.04 / 3.74 |
| Case Mix | 3.33 | 2.97 / 3.16 |
| Adjusted | 5.27 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison | |
|---|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | 20.7% |
20.2% Worse |
|
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | 9.7% |
14.0% Better |
|
| Number of hospitalizations per 1000 long-stay resident days (qm551) | Not Available | ||
| Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) | Not Available | ||
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | Not Available | ||
| Percentage of long-stay residents who lose too much weight (qm404) | Not Available | ||
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | Not Available | ||
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | Not Available | ||
| Percentage of long-stay residents with a urinary tract infection (qm407) | Not Available | ||
| Percentage of long-stay residents who have depressive symptoms (qm408) | Not Available | ||
| Percentage of long-stay residents who were physically restrained (qm409) | Not Available | ||
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | Not Available | ||
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | Not Available | ||
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | Not Available | ||
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 98.2% |
88.2% Better |
|
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | 0.8% |
1.8% Better |
|
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | Not Available | ||
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | Not Available | ||
| Percentage of high risk long-stay residents with pressure ulcers (qm453) | Not Available | ||
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) | Not Available | ||
| Percentage of short-stay residents who made improvements in function (qm471) | 75.8% |
77.3% Worse |
|
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) | 90.8% |
77.3% Better |
|
Ecumen Lakeshore Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $23,185.61, Complaints filed: 0
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Health) | 03-20-2019 / 04-29-2019 |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. (Health) | 03-20-2019 / 04-29-2019 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (Health) | 03-20-2019 / 04-29-2019 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. (Health) | 03-20-2019 / 04-29-2019 |
| Provide safe and appropriate respiratory care for a resident when needed. (Health) | 03-20-2019 / 04-29-2019 |
| Implement a program that monitors antibiotic use. (Health) | 03-20-2019 / 04-29-2019 |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. (Health) | 03-20-2019 / 04-29-2019 |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. (Fire Safety) | 03-20-2019 / 04-29-2019 |
| Install corridor and hallway doors that block smoke. (Fire Safety) | 03-20-2019 / 04-29-2019 |
| Provide and implement an infection prevention and control program. (Health) | 06-24-2020 / 07-24-2020 |
| Provide and implement an infection prevention and control program. (Health) | 08-13-2020 / 09-21-2020 |
| Have approved installation, maintenance and testing program for fire alarm systems. (Fire Safety) | 04-13-2021 / 05-07-2021 |
| Install corridor and hallway doors that block smoke. (Fire Safety) | 04-13-2021 / 05-07-2021 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. (Fire Safety) | 04-13-2021 / 05-07-2021 |
| Have simulated fire drills held at unexpected times. (Fire Safety) | 04-13-2021 / 05-07-2021 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. (Fire Safety) | 04-13-2021 / 05-07-2021 |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. (Fire Safety) | 04-13-2021 / 05-07-2021 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Health) | 04-15-2021 / 05-30-2021 |
| Observe each nurse aide's job performance and give regular training. (Health) | 04-15-2021 / 05-30-2021 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Health) | 04-15-2021 / 05-30-2021 |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (Health) | 04-15-2021 / 05-30-2021 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Health) | 07-30-2021 / 09-11-2021 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Health) | 07-30-2021 / 09-11-2021 |
| Respond appropriately to all alleged violations. (Health) | 07-30-2021 / 09-11-2021 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. (Fire Safety) | 05-23-2022 / 07-09-2022 |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. (Fire Safety) | 05-23-2022 / 07-09-2022 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (Health) | 05-25-2022 / 07-09-2022 |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Health) | 05-25-2022 / 07-09-2022 |
| 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. (Health) | 05-25-2022 / 07-09-2022 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Health) | 05-25-2022 / 07-09-2022 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Health) | 05-25-2022 / 07-09-2022 |
| Respond appropriately to all alleged violations. (Health) | 05-25-2022 / 07-09-2022 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. (Health) | 05-25-2022 / 07-09-2022 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Health) | 05-25-2022 / 07-09-2022 |
| Provide safe, appropriate pain management for a resident who requires such services. (Health) | 05-25-2022 / 07-09-2022 |
| Post nurse staffing information every day. (Health) | 11-08-2022 / 12-08-2022 |
Hospitals Near Ecumen Lakeshore
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Ecumen Lakeshore.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
ST LUKES HOSPITAL 915 EAST 1ST STREET DULUTH, MN 55805 |
3 |
|
ESSENTIA HEALTH DULUTH 502 EAST SECOND STREET DULUTH, MN 55805 |
4 |
|
COMMUNITY MEMORIAL HOSPITAL 512 SKYLINE BOULEVARD CLOQUET, MN 55720 |
4 |
|
ESSENTIA HEALTH ST MARY'S MEDICAL CENTER 407 EAST THIRD STREET DULUTH, MN 55805 |
5 |
|
LAKE VIEW MEMORIAL HOSPITAL 325 ELEVENTH AVE TWO HARBORS, MN 55616 |
Not Available |
|
ST MARYS HOSPITAL SUPERIOR 3500 TOWER AVE SUPERIOR, WI 54880 |
Not Available |
Medical Professionals Associated with Ecumen Lakeshore
These are the doctors who are affiliated with Ecumen Lakeshore. The data is from the most recent period. Historical data is not available.
- ANNA ROSENBERG ( NURSE PRACTITIONER - ST LUKES HOSPITAL OF DULUTH )
- HANNAH NORDSKOG ( NURSE PRACTITIONER - THE DULUTH CLINIC LTD )
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for Ecumen Lakeshore
Five different rating results plus detailed inspection numbers and quality measures for Ecumen Lakeshore.
Covid Infections at Ecumen Lakeshore
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for Ecumen Lakeshore
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for Ecumen Lakeshore
A list of all of the registered owners for Ecumen Lakeshore. This includes direct and indirect owners and managers.
Noted Deficiencies for Ecumen Lakeshore
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does Ecumen Lakeshore compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in DULUTH, MN
Homes that you should consider. A list ranking the best skilled nursing facilities in DULUTH based on their weighted inspection score as of April 01, 2023.
Worst Nursing Homes in DULUTH, MN
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in DULUTH based on their weighted inspection score as of April 01, 2023.
Other Data Periods:
Data on Ecumen Lakeshore is available for the following periods:
