Cycle 1
Health 2025-08-21 · Fire 2025-08-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Duluth, MN
Viewcrest Health Center
3-star overall rating with 3-star inspections with $60,781 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3111 Church Street, Duluth, MN
(218) 727-8801
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
83
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
St. Francis Health Services
Operator or chain grouping
Approved since
1987-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.91
Registered nurse staffing
LPN hours / resident day
0.33
Licensed practical nurse staffing
Aide hours / resident day
2.53
Nurse aide staffing
Weekend hours
3.25
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
97.3%
12.9 pts worse
|
93.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
96.1%
0.6 pts worse
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.9%
1.2 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.4% |
4.3%
1.1 pts worse
|
11.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.0% |
4.1%
3.1 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
12.4%
4.8 pts worse
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
17.5%
1.1 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.1%
0.7 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.5% |
22.5%
7 pts worse
|
16.3%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
18.6%
1.1 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.8% |
2.3%
2.5 pts worse
|
1.0%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.5% |
24.8%
5.7 pts worse
|
19.8%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.4%
2.3 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.5% |
88.6%
39.1 pts worse
|
81.7%
32.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
14.0%
6.8 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.9%
0.6 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.3% |
82.7%
5.4 pts worse
|
79.7%
2.4 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
23.1%
9.5 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-21 · Fire 2023-09-21
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-12
G · Actual harm
2024-07-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-08-02
F · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-02
E · Potential for more than minimal harm
2024-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-07-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-02
F · Potential for more than minimal harm
2023-09-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-09-21
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 2023-11-02
D · Potential for more than minimal harm
2023-09-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-02
C · Minimal harm
2023-09-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-11-02
Inspection history
Recent health citations
J · Immediate jeopardy
2025-03-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-07-11
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-07-11
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 2024-08-07
D · Potential for more than minimal harm
2024-07-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-07
D · Potential for more than minimal harm
2024-07-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-07
D · Potential for more than minimal harm
2024-07-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-07
J · Immediate jeopardy
2024-05-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-10
G · Actual harm
2024-02-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-12
F · Potential for more than minimal harm
2023-09-21
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-11-08
F · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-09-21
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-09-21
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-09-21
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-09-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
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 2023-11-08
D · Potential for more than minimal harm
2023-09-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
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 2023-11-08
D · Potential for more than minimal harm
2023-09-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-09-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-08
Penalties and ownership
What sits behind the stars
$26,685
2025-03-21
Fine
Fine · fine $26,685
Fine
$10,839
2024-07-11
Fine
Fine · fine $10,839
Fine
$14,433
2024-05-14
Fine
Fine · fine $14,433
Fine
$8,824
2024-02-14
Fine
Fine · fine $8,824
Fine
Ownership
St. Francis Health Services Of Morris, Inc
5% Or Greater Direct Ownership Interest · Organization
Bach, Curtis
Operational/Managerial Control · Individual
Bach, Curtis
Corporate Director · Individual
Bach, Curtis
Corporate Officer · Individual
Barry, Heidi
Operational/Managerial Control · Individual
Big Stone Therapies Inc
Operational/Managerial Control · Organization
Boyum, Britney
Operational/Managerial Control · Individual
Burrows, Amanda
Operational/Managerial Control · Individual
Caspers, Megan
Operational/Managerial Control · Individual
Dripps, Daniel
Operational/Managerial Control · Individual
Dripps, Daniel
Corporate Director · Individual
Edin, Colt
Operational/Managerial Control · Individual
Ehlers, Douglas
Operational/Managerial Control · Individual
Ehlers, Douglas
Corporate Director · Individual
Eide Bailly Llp
Operational/Managerial Control · Organization
Fishel, Chester
Operational/Managerial Control · Individual
Goodnough, Jennifer
Operational/Managerial Control · Individual
Goodnough, Jennifer
Corporate Director · Individual
Gramm, Timothy
Operational/Managerial Control · Individual
Gramm, Timothy
Corporate Director · Individual
Granheim, Kascie
Operational/Managerial Control · Individual
Hanneken, Michelle
Operational/Managerial Control · Individual
Hejhal, Roxanne
Operational/Managerial Control · Individual
Hofmann, Reed
Operational/Managerial Control · Individual
Laflamme, Darren
Operational/Managerial Control · Individual
Lair, Michael
Operational/Managerial Control · Individual
Lair, Michael
Corporate Director · Individual
Letich, Elizabeth
Operational/Managerial Control · Individual
Lienemann, Steven
Operational/Managerial Control · Individual
Lienemann, Steven
Corporate Director · Individual
Luetmer, John
Operational/Managerial Control · Individual
Luetmer, John
Corporate Director · Individual
Marlow, Jina
Operational/Managerial Control · Individual
Nelson, Patrick
Operational/Managerial Control · Individual
Nelson, Patrick
Corporate Director · Individual
Oliphant, Miranda
Operational/Managerial Control · Individual
Peterson-Devries, Camilla
Operational/Managerial Control · Individual
Peterson-Devries, Camilla
Corporate Officer · Individual
Raw, Carol
Operational/Managerial Control · Individual
Raw, Carol
Corporate Director · Individual
Rentz, Laura
Operational/Managerial Control · Individual
Rentz, Laura
Corporate Director · Individual
Rentz, Mark
Operational/Managerial Control · Individual
Rentz, Paul
Operational/Managerial Control · Individual
Rentz, Paul
Corporate Director · Individual
Ryan, Benjamin
Operational/Managerial Control · Individual
Ryan, Geoffry
Operational/Managerial Control · Individual
Schneider, Todd
Operational/Managerial Control · Individual
Schneider, Todd
Corporate Director · Individual
St. Francis Health Services Of Morris, Inc
Operational/Managerial Control · Organization
Stock, Kelsey
Operational/Managerial Control · Individual
Tepovich, Nicholas
Operational/Managerial Control · Individual
Thompson, Renee
Operational/Managerial Control · Individual
Tomoson, April
Operational/Managerial Control · Individual
Walker, Amy
Operational/Managerial Control · Individual
Wick, Ashley
Operational/Managerial Control · Individual
Wiese, Lorraine
Operational/Managerial Control · Individual
Wiese, Lorraine
Corporate Director · Individual
Wolf, Jordan
Operational/Managerial Control · Individual
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1-star overall rating with 2-star inspections with $244,730 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
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1-star overall rating with 1-star inspections with abuse icon flag with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Bayshore Residence And Rehabilitation Center
Duluth, MN
1-star overall rating with 1-star inspections with $132,398 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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