1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Duluth, MN
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
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
Chain footprint
14 facilities
Chain averages 3 overall / 2 health / 4 staffing / 3 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
Staffing
RN hours / resident day
0.91
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
4,974
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9911
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.99
Baseline 19.93% · Performance 19.12% · Measure score 4.99 · Achievement 4.99 · Improvement 2.30
Healthcare-associated infections
3.76
Baseline 7.80% · Performance 6.71% · Measure score 3.76 · Achievement 3.76 · Improvement 3.38
Total nurse turnover
2.73
Baseline 60.95% · Performance 52.52% · Measure score 2.73 · Achievement 2.73 · Improvement 1.83
Adjusted total nurse staffing
3.69
Baseline 4.79 hours · Performance 4.13 hours · Measure score 3.69 · Achievement 3.69 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.56% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 9.09% · Lower 95% interval 6.84% |
| Discharge to community | 52.02% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 48% · Lower 95% interval 41.42% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.17% |
95.27%
1.1 pts worse
|
Numerator 97 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 54.44% |
53.69%
0.8 pts better
|
Numerator 49 · Denominator 90 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 40 · Denominator 90 |
| Pressure ulcers or injuries, new or worsened | 3.88% |
2.29%
1.6 pts worse
|
Numerator 4 · Denominator 103 · Adjusted rate 4.09% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 3.96% |
8.2%
4.2 pts worse
|
Numerator 4 · Denominator 101 |
| Staff flu vaccination coverage | 12.59% |
42%
29.4 pts worse
|
Numerator 17 · Denominator 135 |
| Discharge function score | 54.44% |
56.45%
2 pts worse
|
Numerator 49 · Denominator 90 |
| Transfer of health information to provider | 93.88% |
95.95%
2.1 pts worse
|
Numerator 46 · Denominator 49 |
| Transfer of health information to patient | 90.48% |
96.28%
5.8 pts worse
|
Numerator 19 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 36.67% |
25.2%
11.5 pts better
|
Numerator 22 · Denominator 60 |
Quality measures
| 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 · Adjusted 1.2 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| 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 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 85.7% · Q2 80.3% · Q3 77.6% · Q4 93.0% · 4Q avg 84.4% |
| 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 · 4Q avg 95.5% |
| 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 · Q1 3.2% · Q2 1.6% · Q3 3.0% · Q4 2.8% · 4Q avg 2.7% · Used in QM five-star |
| 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 · Q1 10.7% · Q2 7.1% · Q3 4.7% · Q4 0.0% · 4Q avg 5.4% |
| 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 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 1.8% · 4Q avg 1.0% |
| 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 · Q1 13.3% · Q2 16.7% · Q3 18.5% · Q4 19.6% · 4Q avg 17.2% |
| 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 · Q1 18.4% · Q2 16.7% · Q3 23.3% · Q4 15.9% · 4Q avg 18.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.4% · 4Q avg 0.8% |
| 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 · Q3 34.7% · Q4 15.1% · 4Q avg 29.5% · Used in QM five-star |
| 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 · Q1 24.4% · Q2 10.9% · Q3 31.4% · Q4 12.7% · 4Q avg 19.7% · Used in QM five-star |
| 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 · Q1 5.9% · Q2 4.9% · Q3 7.3% · Q4 1.3% · 4Q avg 4.8% · Used in QM five-star |
| 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 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 23.2% · Q2 35.6% · Q3 34.5% · Q4 29.1% · 4Q avg 30.5% |
| 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 · Q1 9.5% · Q2 3.5% · Q3 9.3% · Q4 8.2% · 4Q avg 7.7% · Used in QM five-star |
| 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 · Q1 43.8% · Q2 49.1% · Q3 53.1% · Q4 53.1% · 4Q avg 49.5% |
| 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 · Adjusted 7.2% · Observed 6.7% · Expected 10.3% · Used in QM five-star |
| 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 · Q1 1.8% · Q2 3.2% · Q3 2.9% · Q4 1.9% · 4Q avg 2.5% · Used in QM five-star |
| 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 · 4Q avg 77.3% |
| 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 · Adjusted 13.6% · Observed 11.1% · Expected 19.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
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
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-12
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-08-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-02
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-02
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
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-02
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-02
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
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-02
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-11-02
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
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
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
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-07
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-07
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-12
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
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-08
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-11-08
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-11-08
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-11-08
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-08
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
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-08
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-08
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
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-11-08
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-08
Penalties and ownership
Fine · fine $26,685
Fine
Fine · fine $10,839
Fine
Fine · fine $14,433
Fine
Fine · fine $8,824
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
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