Cycle 1
Health 2025-04-16 · Fire 2025-04-16
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Breckenridge, MN
St Francis Home
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
2400 St Francis Drive, Breckenridge, MN
(218) 643-3000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1984-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.30
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.58
CMS adjusted RN staffing hours
Adjusted total hours
5.23
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,343
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0126
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.32
Baseline 46.15% · Performance 37.84% · Measure score 6.32 · Achievement 6.32 · Improvement 3.40
Adjusted total nurse staffing
5.16
Baseline 3.70 hours · Performance 4.55 hours · Measure score 5.16 · Achievement 5.16 · Improvement 3.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 74 |
| Staff flu vaccination coverage | 73.02% |
42%
31 pts better
|
Numerator 46 · Denominator 63 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.9%
1.1 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 2.9% · Q3 2.8% · Q4 2.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.3%
3.5 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
4.1%
0.2 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.3% · Q3 8.6% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
12.4%
6.7 pts worse
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 18.8% · Q3 25.7% · Q4 23.3% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
17.5%
1.9 pts better
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 15.4% · Q3 14.3% · Q4 18.5% · 4Q avg 15.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.6% |
22.5%
3.9 pts better
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
18.6%
4.5 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 6.5% · Q3 5.9% · Q4 13.3% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 5.6% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
24.8%
3.5 pts better
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 16.2% · Q3 19.1% · Q4 27.2% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.4%
0.1 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.7% · Q3 7.2% · Q4 6.5% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
88.6%
4.3 pts better
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 92.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-17 · Fire 2024-07-17
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-08-08 · Fire 2023-08-08
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-16
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 2025-05-16
D · Potential for more than minimal harm
2025-04-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-16
F · Potential for more than minimal harm
2023-08-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-08-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-11
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 2024-09-30
E · Potential for more than minimal harm
2024-07-17
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-07-17
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 2024-08-09
D · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
E · Potential for more than minimal harm
2023-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-08-08
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 2023-08-31
D · Potential for more than minimal harm
2023-08-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-31
C · Minimal harm
2023-08-08
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-08-31
Penalties and ownership
What sits behind the stars
Ownership
Commonspirit Health
5% Or Greater Direct Ownership Interest · Organization
Althoff, Tamera
Corporate Director · Individual
Anderson, Daniel
Corporate Director · Individual
Catholic Health Initiatives
Operational/Managerial Control · Organization
Dean, Lloyd
Corporate Officer · Individual
Dohman, Gloria
Corporate Director · Individual
Grossman, Charlene
Corporate Director · Individual
Hansen, Carter
Corporate Director · Individual
Mccartney, Michael
Corporate Director · Individual
Nelson, David
Corporate Officer · Individual
Nelson, David
W-2 Managing Employee · Individual
O'quinn, Marvin
Corporate Officer · Individual
Reinke, Doreen
Corporate Director · Individual
Ross, Jay
Corporate Officer · Individual
Ross, Jay
W-2 Managing Employee · Individual
St Francis Medical Center
Operational/Managerial Control · Organization
Stowman, Amber
Corporate Officer · Individual
Stowman, Amber
W-2 Managing Employee · Individual
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