Cycle 1
Health 2024-12-12 · Fire 2024-12-12
13 health deficiencies
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Duluth, MN
Franciscan Health Center
1-star overall rating with 2-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3910 Minnesota Avenue, Duluth, MN
(218) 727-8933
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
38
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
St. Francis Health Services
Operator or chain grouping
Approved since
1983-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.33
Registered nurse staffing
LPN hours / resident day
0.19
Licensed practical nurse staffing
Aide hours / resident day
2.25
Nurse aide staffing
Weekend hours
3.16
Weekend nurse staffing
RN turnover
24%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
96.1%
6.4 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.9%
1.5 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
4.3%
3.5 pts worse
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.8% |
4.1%
1.3 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
12.4%
4.1 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
17.5%
5.9 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 47.3% |
22.5%
24.8 pts worse
|
16.3%
31 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.0% |
18.6%
14.4 pts worse
|
14.9%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.2% |
2.3%
2.9 pts worse
|
1.0%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.6%
0.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.5% |
24.8%
8.7 pts worse
|
19.8%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.4%
3.2 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
88.6%
7.7 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-31
F · Potential for more than minimal harm
2023-10-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-20
C · Minimal harm
2023-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-01-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-18
F · Potential for more than minimal harm
2023-01-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-18
F · Potential for more than minimal harm
2023-01-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-18
F · Potential for more than minimal harm
2023-01-06
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-02-18
F · Potential for more than minimal harm
2023-01-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-02-18
F · Potential for more than minimal harm
2023-01-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-18
E · Potential for more than minimal harm
2023-01-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
F · Potential for more than minimal harm
2024-12-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-12
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-08-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-03-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-15
E · Potential for more than minimal harm
2023-10-05
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-05
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-05
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-05
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-22
D · Potential for more than minimal harm
2023-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-22
B · Minimal harm
2023-10-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-22
F · Potential for more than minimal harm
2023-03-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-01-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-18
F · Potential for more than minimal harm
2023-01-06
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-02-18
E · Potential for more than minimal harm
2023-01-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-02-18
E · Potential for more than minimal harm
2023-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-18
D · Potential for more than minimal harm
2023-01-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-18
D · Potential for more than minimal harm
2023-01-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-18
D · Potential for more than minimal harm
2023-01-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-18
D · Potential for more than minimal harm
2023-01-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-18
Penalties and ownership
What sits behind the stars
Ownership
St. Francis Health Services Of Morris, Inc
5% Or Greater Direct Ownership Interest · Organization
Chambers, Mari
Operational/Managerial Control · Individual
Chambers, Mari
Corporate Officer · Individual
Chambers, Mari
W-2 Managing Employee · Individual
Goodnough, Jennifer
Corporate Director · Individual
Nelson, Patrick
Corporate Director · Individual
Peterson-Devries, Camilla
Operational/Managerial Control · Individual
Peterson-Devries, Camilla
Corporate Officer · Individual
Peterson-Devries, Camilla
W-2 Managing Employee · Individual
Raw, Carol
Operational/Managerial Control · Individual
Raw, Carol
Corporate Officer · Individual
Raw, Carol
W-2 Managing Employee · Individual
Wagner, Sherry
W-2 Managing Employee · Individual
Wiese, Lorraine
Corporate Director · Individual
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#3
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