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
Staffing
Hours and turnover
RN hours / resident day
1.30
Registered nurse staffing
LPN hours / resident day
0.41
Licensed practical nurse staffing
Aide hours / resident day
2.57
Nurse aide staffing
Weekend hours
3.74
Weekend nurse staffing
RN turnover
39%
Annual RN turnover
Total nurse turnover
37%
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 | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 18.6% |
22.5%
3.9 pts better
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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#3
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