Franciscan Health Center

3910 MINNESOTA AVENUE
DULUTH, MN, 55802
2187278933
CCN: 245258
1
Overall
2
Health
4
Staffing
1
Quality
ChainST. FRANCIS HEALTH SERVICES
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
OIG Federal Exclusion Matches (1)
This facility's name matches one or more entities on the OIG List of Excluded Individuals/Entities (LEIE). Excluded parties are prohibited from participation in Medicare and Medicaid programs.
LJ HOME HEALTH SERVICES, INC
1128b8
Excluded 2002-07-18
Ownership
NameRole%
ST. FRANCIS HEALTH SERVICES OF MORRIS, INC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
GOODNOUGH, JENNIFERCORPORATE DIRECTORNOT APPLICABLE
WIESE, LORRAINECORPORATE DIRECTORNOT APPLICABLE
NELSON, PATRICKCORPORATE DIRECTORNOT APPLICABLE
CHAMBERS, MARICORPORATE OFFICERNOT APPLICABLE
PETERSON-DEVRIES, CAMILLACORPORATE OFFICERNOT APPLICABLE
RAW, CAROLCORPORATE OFFICERNOT APPLICABLE
CHAMBERS, MARIOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
RAW, CAROLOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
PETERSON-DEVRIES, CAMILLAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
PETERSON-DEVRIES, CAMILLAW-2 MANAGING EMPLOYEENOT APPLICABLE
CHAMBERS, MARIW-2 MANAGING EMPLOYEENOT APPLICABLE
RAW, CAROLW-2 MANAGING EMPLOYEENOT APPLICABLE
WAGNER, SHERRYW-2 MANAGING EMPLOYEENOT APPLICABLE
Health Deficiencies (37)
2026-01-29 · Health
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2024-12-12 · Health
E
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
D
F887 · Infection Control Deficiencies
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.
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F761 · Pharmacy Service Deficiencies
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.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F740 · Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
E
F574 · Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
2024-08-09 · Health
D
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2024-03-19 · Health
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2023-10-05 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F758 · Pharmacy Service Deficiencies
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.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
B
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F636 · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
E
F570 · Resident Rights Deficiencies
Assure the security of all personal funds of residents deposited with the facility.
E
F568 · Resident Rights Deficiencies
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
2023-03-01 · Health
F
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2023-01-06 · Health
F
F882 · Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
E
F584 · Resident Rights Deficiencies
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.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.77
3.68
RN Hrs/Resident/Day
1.33
0.54
LPN Hrs/Resident/Day
0.19
0.81
CNA Hrs/Resident/Day
2.25
2.33
PT Hrs/Resident/Day
0.09
0.12
Data as of 2026-03-01