Franciscan Health Center

3910 MINNESOTA AVENUE, DULUTH, MN 55802

Facility Assessment 13 federal violations at this facility remain unresolved.

At or above the 2024 benchmark — review inspection history before visiting.

Quality Breakdown

RN Staffing Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.	1.33 — At or above the repealed 0.55 hr benchmark
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles) Violations found during federal inspections, with how many remain open and how many involved actual harm.	Total 41 Outstanding 13 Actual harm or worse (G–L) 0
CMS Ratings Overall and Staffing quality ratings from CMS (1-5 stars).	Quality: ★☆☆☆☆ (1/5) Staffing: ★★★★☆ (4/5)
NursingHomeGrade Score	32/100

Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

41 deficiencies found. 28 corrected. None involved actual harm. — 13 still outstanding

Most recent inspection (January 29, 2026)

E Potential harm — pattern F0880 Status: Outstanding — No Plan

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0883 Status: Outstanding — No Plan

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0887 Status: Outstanding — No Plan

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.

Infection Control Deficiencies — Deficient, Provider has no plan of correction

F Potential harm — widespread F0725 Status: Outstanding — No Plan

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0812 Status: Outstanding — No Plan

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has no plan of correction

E Potential harm — pattern F0761 Status: Outstanding — No Plan

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.

Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0684 Status: Outstanding — No Plan

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0686 Status: Outstanding — No Plan

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0695 Status: Outstanding — No Plan

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0677 Status: Outstanding — No Plan

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0641 Status: Outstanding — No Plan

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0645 Status: Outstanding — No Plan

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0657 Status: Outstanding — No Plan

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Inspection cycle 2 (December 12, 2024)

E Potential harm — pattern F0919 Status: Corrected

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

D Potential harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0943 Status: Corrected

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

D Potential harm — isolated F0883 Status: Corrected

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

D Potential harm — isolated F0887 Status: Corrected

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

F Potential harm — widespread F0725 Status: Corrected

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

E Potential harm — pattern F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

F Potential harm — widespread F0761 Status: Corrected

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

D Potential harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

D Potential harm — isolated F0698 Status: Corrected

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

D Potential harm — isolated F0740 Status: Corrected

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

D Potential harm — isolated F0655 Status: Corrected

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

E Potential harm — pattern F0574 Status: Corrected

The resident has the right to receive notices in a format and a language he or she understands.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

Inspection cycle 3 (March 19, 2024)

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 15, 2024

D Potential harm — isolated F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 15, 2024

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

D Potential harm — isolated F0757 Status: Corrected

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

D Potential harm — isolated F0758 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

D Potential harm — isolated F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

D Potential harm — isolated F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

D Potential harm — isolated F0636 Status: Corrected

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

B No harm — pattern F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

D Potential harm — isolated F0561 Status: Corrected

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

E Potential harm — pattern F0568 Status: Corrected

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

E Potential harm — pattern F0570 Status: Corrected

Assure the security of all personal funds of residents deposited with the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 22, 2023

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Franciscan Health Center

Quality Breakdown

Inspection Deficiencies

Most recent inspection (January 29, 2026)

Inspection cycle 2 (December 12, 2024)

Inspection cycle 3 (March 19, 2024)

How We Stay Independent

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