Ecumen Home Care Lakeshore
A home health agency in Duluth, Minnesota 55804
4000 London Road, Duluth, Minnesota 55804. (218) 625-7848.
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The short answer
Record last released by CMS on Oct 21, 2026.
- 3.5of 5 quality of patient care rating
- 3of 5 patient survey rating
- 2 deficiencies cited in the last three years
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Jul 10, 2025: a recertification inspection.
2 deficiencies cited in the last three years.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Jul 2025. Most serious: Element-level. The last 3 years, to Oct 24, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
Jul 10, 2025: recertification inspection2 deficiencies
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Written Notice For Non-Covered Care
The inspectors’ words, 238 words
“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on interview and document review the facility failed to give the Notice of Medicare Non-Coverage (CMS 10123-NOMNC) at least 48 hours prior to discharge from services. This had the ability to effect 1 of 3 (P8) patients reviewed for discharge process. Findings include: P8’s plan of care (POC) dated 2/7/25 to 4/7/25 indicated P8 received physical therapy and occupational therapy services. P8’s Discharge Order dated 3/4/25 at 2:35 p.m., indicated P8 was discharged on 3/4/25, from home health agency services. P8’s CMS 10123-NOMNC dated 3/4/25 indicated last day of Medicare coverage was 3/4/25. During an interview on 7/10/25 at 1:08 p.m. the registered nurse clinical director (RNCD) stated all skilled patients would receive the CMS 10123-NOMNC at least 48hrs prior to discharge from services. P8’s chart was reviewed and the RNCD acknowledged P8 received the CMS 10123-NOMNC the same day of discharge from services. Facility Policy Expedited Determination Policy undated, each Medicare beneficiary would be notified in writing using the CMS 10123 no later than two days before covered home care services would end.”
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Only As Ordered By A Physician
The inspectors’ words, 299 words
“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and document review the facility failed to setup medications as ordered by the provider. This affected 1 of 1 (P5) patient reviewed for medication setup. R5’s plan of care (POC) dated 5/18/25 to 7/16/25, indicated P5 received Cholecalciferol (Vitamin D3) 400 international units (IU) two times a day (BID) by mouth. During an observation on 7/9/25 at 1:18 p.m., licensed practical nurse (LPN)-A set up Vitamin D3 one time a day for the two weeks’ worth of medications R5 would take. During an interview on 7/9/25 at 2:08 p.m., LPN-A stated there had been confusion on if P5 should take one table one time a day or BID. The current order in the POC was to give one BID. P5 would sometimes take 1 capsule and other times take 2 capsules. It just depended on what he wanted to take. The staff are pretty sure it should be one capsule once a day, so I have just been setting up a once-a-day dose of Vitamin D3 for P5. During an interview on 7/10/25 at 1:07 p.m., the registered nurse clinical director (RNCD) stated the medication orders on the POC were the correct orders. When the meds are set up, they should be set up according to the POC. IF there is a question related to the ordered medications the nurse should request clarification from the provider but follow the current order until the clarification is received and changed on the active orders. Facility policy Medication Administration undated, indicated medications and treatments would only be administered or set up only as ordered by the provider.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 10, 2025 | Recertification inspection | 2 deficiencies cited |
Is it certified?
- Medicare-certified home health agency since Jun 7, 1967.
- Ownership: non-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
CMS, Home Health Care Agencies. Released Oct 21, 2026. Updated quarterly.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for home health agencies, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR home health inspection reports. Released Oct 20, 2026. Updated monthly.
Who does the caring?
- Offers nursing care, physical therapy, occupational therapy, speech pathology and home health aide services.
- Doesn’t offer medical social services.
- CMS doesn’t publish staffing levels for home health agencies.
CMS, Home Health Care Agencies. Released Oct 21, 2026. Updated quarterly.
Who owns it?
- Ecumen owns 100% directly since Apr 28, 2010.
- Ecumen runs it.
- 46 owners or officers are people: James Stephen Mcalpine (corporate officer, 100%); Tina Marie Palmer (corporate officer, 100%); Clair Ann Juarez (managing employee (on the payroll), 100%); Clair Ann Juarez (runs it (operational or managerial control), 100%); Cyrus Mun Batheja (corporate officer, 100%); Cyrus Mun Batheja (runs it (operational or managerial control), 100%); Tami Jo Haley (corporate officer, 100%); Douglas Clyde Harrison (corporate officer, 100%); Marcia Kull (corporate director, 0%); Marcia Kull (runs it (operational or managerial control)); Jan Marie Conlin (corporate director); Jan Marie Conlin (runs it (operational or managerial control)); Peter Burton Schuna (corporate director); Peter Burton Schuna (runs it (operational or managerial control)); James Stephen Mcalpine (managing employee (on the payroll)); James Stephen Mcalpine (runs it (operational or managerial control)); Tina Marie Palmer (managing employee (on the payroll)); Tina Marie Palmer (runs it (operational or managerial control)); John Petraborg (corporate director, 0%); John Petraborg (runs it (operational or managerial control)); Jeanette Lynne Augustson (corporate director); Jeanette Lynne Augustson (runs it (operational or managerial control)); Brent D Iserman (corporate director); Brent D Iserman (runs it (operational or managerial control)); Diane Haugen Pederson (corporate director, 0%); Diane Haugen Pederson (runs it (operational or managerial control), 0%); Margene Toraason Reno (corporate director, 0%); Margene Toraason Reno (runs it (operational or managerial control), 0%); Susan R Bergstrom (corporate director); Susan R Bergstrom (runs it (operational or managerial control)); Cyrus Mun Batheja (managing employee (on the payroll)); Tami Jo Haley (managing employee (on the payroll)); Tami Jo Haley (runs it (operational or managerial control)); Joy Marie Plamann (corporate director); Joy Marie Plamann (runs it (operational or managerial control)); Douglas Clyde Harrison (managing employee (on the payroll)); Douglas Clyde Harrison (runs it (operational or managerial control)); Nils Warren Snyder (corporate director); Nils Warren Snyder (runs it (operational or managerial control)); Sharlene Miata Getaweh (corporate director); Sharlene Miata Getaweh (runs it (operational or managerial control)); Mary W Frey (corporate director); Mary W Frey (runs it (operational or managerial control)); Emily Ann Laxdal Sommer (corporate officer); Emily Ann Laxdal Sommer (managing employee (on the payroll)); Emily Ann Laxdal Sommer (runs it (operational or managerial control)).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Home Health Agency All Owners and Home Health Agency Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Ecumen | Owns 5% or more directly | 100% | Apr 28, 2010 |
| Ecumen | Runs it (operational or managerial control) | 100% | Jun 1, 2010 |
How do patients fare?
- CMS rates its quality of patient care 3.5 of 5.
- Patients rate it 3 of 5 in CMS’s patient survey (65 surveys completed): 80% rated it 9 or 10 out of 10, and 75% would definitely recommend it.
- CMS compares it with the national rate: discharged to the community, better; potentially preventable hospital stays, the same; potentially preventable readmissions after discharge, the same.
CMS, Home Health Care Agencies and Home Health Patient Survey. Released Oct 21, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Quality of patient care ratingCMS star rating, 1 to 5 in half stars | 3.5 of 5 |
| Patient survey ratingCMS star rating from its survey of the agency’s patients, 1 to 5 | 3 of 5 |
| Discharged to the communityCMS’s risk-adjusted rate, compared with the national rate | 94.37% (better than the national rate) |
| Potentially preventable hospital staysCMS’s risk-adjusted rate, compared with the national rate | 7.99% (same as the national rate) |
| Potentially preventable readmissions after dischargeCMS’s risk-adjusted rate, compared with the national rate | 4.30% (same as the national rate) |
How does it compare nearby?
- Of the 10 agencies CMS’s data show serving patients in ZIP code 55804, where this agency’s office is, 9 have a quality of patient care rating; the middle one is 3 of 5, and this one is rated 3.5 of 5.
CMS, Home Health ZIP Codes and Home Health Care Agencies. Released Oct 21, 2026. Updated quarterly.
| Place | Quality rating |
|---|---|
| Ecumen Home Care Lakeshore This home health agency | 3.5 |
| Aveanna Home Health | 4.5 |
| Aspirus St. Luke’s at Home - Home Care - Duluth | 2 |
| Centerwell Home Health | 4 |
| Benedictine Health Center Duluth | 2.5 |
| Senior Friend Home Care | Not given |
| Essentia Health Moose Lake Home Care | 3 |
| Regency Home Healthcare Services, LLC | 1 |
| Tru Home Health, Inc. | 3 |
| Caringedge Healthcare of Hermantown LLC | 2.5 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for home health agencies, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- QCOR says some of its home health reports are accurate or available only through May 19, 2021, because of a systems migration.
- Many home health agencies are inspected by a private accrediting organisation instead of the state, and QCOR’s home health file doesn’t appear to include those inspections: no inspection on record here doesn’t mean none took place.
Sources
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Centers for Medicare & Medicaid Services, Home Health Care Agencies (6jpm-sxkc).
Released Oct 21, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health Patient Survey (ccn4-8vby).
Released Oct 21, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR home health inspection reports (HHA_2567s_2018_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 24, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health Agency All Owners (fc009b2d-7846-44b1-b4a1-692f0c143879).
Released Sep 29, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health Agency Enrollments (15f64ab4-3172-4a27-b589-ebd67a6d28aa).
Released Sep 29, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Home Health ZIP Codes (m5eg-upu5).
Released Oct 21, 2026 and checked Oct 24, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 24, 2026.
From the agency
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Replies
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Paid listing
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