Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franciscan Health Center during CMS and state inspections, most recent first.
The facility failed to report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after a male resident groped a female resident’s breasts without consent in the dining room while approaching his wife. A RN observed the incident, redirected the involved resident, and notified law enforcement and responsible parties, while the affected resident showed no visible distress and later had little recall of the event. The incident was not reported to the State Agency until several hours later, after most of the internal investigation had been completed, and the social worker acknowledged she was unaware that the allegation needed to be reported first and within 2 hours, contrary to facility policy and regulatory requirements.
The facility experienced significant staffing shortages, resulting in delayed medication administration for several residents and inadequate care for a resident with pressure ulcers. Nurses were overwhelmed with responsibilities, leading to late medication passes, while nursing assistants struggled to provide timely repositioning for residents. Interviews and reports confirmed ongoing staffing deficiencies, particularly on weekends and certain shifts, impacting the quality of care.
The facility failed to ensure medications and supplies in the medication storage room were not expired, affecting all 39 residents. Observations revealed expired blood tubes, viral panel swabs, Hibiclens, and Bacitracin ointment. The DON acknowledged the issue, noting the night shift's responsibility to check for expired items, but no check-off sheet was in place to ensure completion.
The facility failed to post ombudsman information at an accessible level for residents, particularly those in wheelchairs. During a resident council meeting, residents expressed difficulty in accessing state inspection postings due to their height. A review confirmed that the ombudsman information was placed too high, approximately six inches from the ceiling, making it inaccessible. The DON verified this issue, which violates resident rights requiring accessible information posting.
A facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate. A resident with multiple diagnoses, including anxiety and dysphagia, received medications late due to a nurse's heavy workload. The nurse was responsible for administering medications to 23-24 residents, including those requiring special precautions, leading to delays in medication delivery.
The facility failed to ensure that call lights in resident bathrooms were accessible from the floor, affecting five residents. Observations showed that cords were either too short or had knots, preventing them from reaching the floor, and one call light was non-functional. Staff interviews revealed a lack of awareness about regulations for call light cord length, and the maintenance director was not informed of the issues.
A facility failed to provide a newly admitted resident with a copy of their baseline care plan, which included essential care needs and interventions. Despite the care plan being developed, neither the resident nor their representative received a copy, as confirmed by interviews with the resident, family, and staff.
A resident with pressure ulcers was not repositioned timely, as required by their care plan, leading to a deficiency in care. The resident, dependent on staff for bed mobility, was left in the same position for over three hours, resulting in an uncovered and actively bleeding wound. The facility's policy required repositioning based on individual assessments, which was not followed in this instance.
A facility failed to establish an effective communication system with an outside dialysis center for a resident with end-stage renal disease and type 2 diabetes mellitus. The resident's care plan required dialysis on specific days and included staff responsibilities for monitoring and communication. However, the dialysis agreement lacked essential information, and the facility's policy on Dialysis Management was not followed, leading to a deficiency in ensuring continuity of care.
A facility failed to investigate and analyze the underlying causes of a resident's delusions, leading to a deficiency in behavioral health care. The resident exhibited hallucinations and delusions, such as seeing people and animals in her room, over several months. Despite staff training on mental health conditions, the facility did not adequately address these symptoms or adjust the care plan, resulting in insufficient behavioral health services.
A facility failed to ensure proper PPE use when staff exited a Covid-19 positive resident's room. Staff removed N-95 masks inside the room and replaced them with surgical masks, contrary to facility policy and CDC guidelines. Interviews revealed staff were misinformed about proper doffing procedures, leading to potential exposure risks.
The facility failed to maintain up-to-date immunization records and provide vaccine education for new admissions. Two residents lacked immunization histories, and another was not offered a pneumococcal vaccine despite eligibility. Additionally, three residents were not educated or offered the influenza vaccine, with no documentation of vaccine declinations. Staff interviews revealed uncertainty about vaccination status and procedures for handling refusals.
The facility failed to educate and offer COVID-19 vaccinations to residents upon admission. A resident with chronic heart failure and other conditions had a record of a past COVID-19 vaccine, but staff were unsure if vaccines were offered upon admission. Another resident with hypertensive heart disease and other conditions had no immunization history, and staff assumed the resident was anti-vaccine without documentation. A third resident with spastic hemiplegia and stroke also lacked an immunization history, and staff were unsure if follow-up occurred. The facility's policy to document and offer vaccines upon admission was not followed.
A resident with severe cognitive impairments and multiple mental health disorders was involved in an inappropriate sexual encounter with a housekeeper, who was unaware of the prohibition against relationships with residents. The incident was documented by a nurse but not reported for investigation, despite the resident's care plan indicating a history of inappropriate behavior. An occupational therapy assistant assessed the resident as not cognitively intact enough to consent, highlighting the facility's failure to protect the resident from potential abuse.
A resident with severe cognitive impairments reported a romantic and physical encounter with a housekeeper, which was documented by an RN but not reported to the State Agency within the required two-hour timeframe. The facility's policy mandates immediate reporting of suspected maltreatment, which was not followed, resulting in a deficiency.
The facility did not ensure that a housekeeper received required training on abuse, neglect, and exploitation. The housekeeper could not recall the last training, and records showed no training since 2021. The DON and administrator confirmed that training should occur upon hire and annually, as per the facility's policy.
Failure to Timely Report Alleged Sexual Assault to State Agency
Penalty
Summary
The facility failed to timely report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after an incident in which one resident groped another resident’s breasts without consent in the dining room. On the morning of 1/20/26 at approximately 9:15 a.m., a registered nurse (RN-A) observed that a male resident (R1) approached the dining room to greet his wife (R3), moved around a table when asked by an aide, and then came behind another resident (R2) and groped her breasts without her consent. R1 was redirected to his room and educated, and he demonstrated little to no remorse for his actions. RN-A reported that R2 was aware the incident occurred but soon closed her eyes and showed no visible negative reaction or distress, and later staff interviews found R2 had slight to no recall of the incident. Police and the responsible parties for R1 and R2 were notified, and RN-A, who had not worked at the facility for long and was unfamiliar with the residents’ plans of care, stated that the plan of care was nonetheless followed. The facility’s incident report shows that the allegation was reported to the State Agency at 4:25 p.m. on 1/20/26, more than 2 hours after the incident. During an interview on 1/29/26, the social worker stated that the decision was made to report to the State Agency after most of the investigation had been completed and acknowledged she was not aware that the report should have been made first. She agreed that the incident was reported late and not within the 2-hour requirement set by regulations and the facility’s “Maltreatment Reporting Guidelines” policy, which requires immediate reporting, but no later than 2 hours after an allegation of abuse, neglect, financial exploitation, injuries of unknown source, or misappropriation of property.
Staffing Shortages Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely completion of resident care, resulting in delayed administration of morning medications for several residents. Specifically, four residents received their medications late, with one resident receiving their morning medications as late as 1:15 p.m. despite being scheduled for administration between 7:00 a.m. and 10:00 a.m. The registered nurse responsible for medication administration was overwhelmed with the task of passing medications to 23-24 residents, including those requiring additional time for medication crushing and enhanced barrier precautions. In addition to medication delays, the facility also failed to provide adequate assistance for a resident with pressure ulcers who required regular turning and repositioning. The resident, who was dependent on staff for bed mobility, was not repositioned for several hours, leading to a worsening of their wound condition. The nursing assistant responsible for the resident's care was unable to attend to the resident in a timely manner due to a busy morning, resulting in the resident's wound being left uncovered and actively bleeding. Interviews with staff revealed ongoing issues with staffing levels, with nurses and nursing assistants frequently unable to complete their duties within their shifts. The facility's staffing levels were consistently below the planned numbers, particularly on weekends and during certain shifts, leading to increased workloads for the remaining staff. The facility's assessment and payroll-based journal report confirmed these staffing deficiencies, highlighting a pattern of insufficient staffing that impacted the quality of care provided to residents.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that medications and supplies in the medication storage room were not expired, potentially affecting all 39 residents. During an inspection of the locked medication room, it was observed that the lab cart for blood draws contained nine yellow top blood tubes with an expiration date of 10/31/24, all four respiratory viral panel swabs were expired, two bottles of Hibiclens had expiration dates of 8/2024 and 11/2024, and two tubes of Bacitracin ointment had expiration dates of 11/2023. The Director of Nursing (DON) acknowledged that expired medications should not be used due to concerns about potency and efficacy. It was noted that the night shift was responsible for checking for outdated supplies, but there was no check-off sheet to ensure this task was completed. The facility's Night Nurse Weekly Duties document indicated that each Tuesday, the night nurse was to check for dates on opened medications and expired medications on both medication carts, treatment carts, and the medication room, highlighting any dates that expire within the current month.
Inaccessible Posting of Ombudsman Information
Penalty
Summary
The facility failed to ensure that current contact information for all pertinent State Agency and advocacy groups was posted at a level accessible to all residents, particularly those in wheelchairs or with poor eyesight. During a resident council meeting, four residents, all requiring the use of a wheelchair, expressed that they were unaware of where state inspections were posted and noted that some postings were too high to read. A review of the bulletin board in the main dining room revealed that the poster with information regarding the ombudsman was placed approximately six inches from the ceiling, making it inaccessible to residents in wheelchairs. The Director of Nursing confirmed the inaccessibility of the ombudsman information, which is a violation of the Combined Federal and State Resident Rights that require such information to be posted in a form and manner accessible and understandable to residents and their representatives.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 13.79% with four errors out of 29 opportunities. This deficiency involved a resident who was observed during medication passes. The resident, who was moderately cognitively intact, had multiple diagnoses including anxiety, depression, and dysphagia, and required medications to be administered through a gastric tube. The errors were primarily due to the late administration of medications, which were given significantly past their scheduled times. The registered nurse responsible for administering the medications was handling a large workload, passing medications for 23-24 residents, including those requiring crushed medications and enhanced barrier precautions. This workload contributed to the delay in medication administration. The director of nursing confirmed that nurses were responsible for half of the residents in the building and acknowledged the importance of timely medication delivery. The facility's medication delivery schedule was not adhered to, leading to the observed deficiencies.
Inaccessible Call Lights in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call lights were accessible from the bathroom floor in multi-resident bathrooms for five residents. Observations revealed that call light cords in several rooms were either too short or had knots, preventing them from reaching the floor. In one instance, a call light did not function when pulled. Interviews with nursing staff and the maintenance director indicated a lack of awareness regarding the required length of call light cords in bathrooms. Measurements confirmed that the cords were significantly above the floor, with some cords having knots that further reduced their length. The nursing assistant and registered nurses interviewed were not aware of any specific regulations concerning the length of call light cords in resident bathrooms. The maintenance director was not informed of the non-functioning call light and had not received any repair requests. The director of nursing acknowledged the importance of having call lights reach the floor to ensure residents could access them in case of a fall. The facility's call light policy, dated 2017, did not address the required length of call lights in resident bathrooms.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to ensure that a copy of the baseline care plan was provided to a newly admitted resident, identified as R40, or their representative. R40 was admitted with spastic hemiplegia affecting the right dominant side and a nontraumatic intracerebral hemorrhage. The baseline care plan, dated 11/19/24, included short-term goals, health maintenance needs, pain intervention, safety concerns, medication concerns, and designated representative, as well as needs and interventions for eating, toileting, bathing, grooming, dressing, bed mobility, and transfers. However, there was no indication that R40 or their representative had been offered or received a copy of this care plan. Interviews conducted with R40 and their family member revealed that they were not aware of any meetings regarding care plans. The Director of Nursing (DON) stated that the baseline care plan should be reviewed and a copy offered to the resident or their representative. A registered nurse confirmed that while the care plan was developed with the resident, it was not offered to them or their representative. The corporate RN also verified the importance of providing a copy of the baseline care plan to ensure the resident and their family are aware of the plan of care.
Failure to Reposition Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely repositioning for a resident with pressure ulcers, leading to a deficiency in care. The resident, identified as R25, had intact cognition and was diagnosed with Parkinson's with dyskinesia, diabetes mellitus, stage two pressure ulcers in the sacral region and left buttock, dermatitis due to friction or contact with body fluids, and a non-pressure chronic ulcer. R25 was dependent on staff for bed mobility and required repositioning every two to three hours as per the care plan. However, during an observation, R25 was left in the same position from shortly after 7 a.m. until 10:02 a.m., exceeding the recommended repositioning interval. When the nursing assistant (NA-D) finally attended to R25, they discovered the wound was not covered with a dressing and was actively bleeding. The registered nurse (RN-D) was called to clean and dress the wound, noting that it appeared worse than the previous day. RN-D had been conducting weekly wound assessments since the facility's rounding wound provider stopped visiting. Despite the worsening condition of the wound, the resident's provider was aware and visited the facility weekly. The facility's repositioning policy required residents to be repositioned based on individual assessments, but this was not adhered to in R25's case, contributing to the deficiency.
Failure to Implement Effective Dialysis Communication System
Penalty
Summary
The facility failed to establish an effective communication system with an outside dialysis facility, which is crucial for ensuring continuity of care and reducing the risk of complications for a resident requiring dialysis services. The resident, who had intact cognition and was diagnosed with end-stage renal disease and type 2 diabetes mellitus, was receiving dialysis care while residing at the nursing facility. The resident's care plan indicated that dialysis was scheduled for Monday, Wednesday, and Friday, and included staff responsibilities such as assessing the dialysis site for bleeding or drainage, updating the provider or dialysis unit with any concerns, recording weights from the dialysis unit, and observing for signs of infection. During interviews, it was revealed that the health unit coordinator stated that a dialysis communication sheet was supposed to accompany the resident to the dialysis center and be returned to the facility, but the resident did not have a dialysis agreement in their electronic medical record. The director of nursing emphasized the importance of a dialysis agreement for better communication and continuity of care. The dialysis agreement, dated after the deficiency was noted, lacked critical information such as the dialysis contact person and the name and address of the hospital for emergency dialysis. The facility's policy on Dialysis Management required a comprehensive agreement to manage the resident's care, including details on medical and non-medical emergencies and the process for information exchange, which was not adhered to in this case.
Failure to Investigate Resident's Delusions
Penalty
Summary
The facility failed to investigate, review, and analyze the underlying causes of a resident's delusions, leading to a deficiency in providing necessary behavioral health care and services. The resident, identified as R11, exhibited behaviors of hallucinations and delusions, as documented in her quarterly Minimum Data Set (MDS). Despite having no cognitive impairment diagnosis, R11 displayed significant behavioral changes, including hallucinations of people and animals in her room, confusion, and delusional thoughts about children and animals. These behaviors were consistently documented by staff over several months, yet there was no evidence of a thorough investigation or analysis of these symptoms. R11's care plan included interventions such as monitoring for cognitive changes, orienting her to time and place, and providing redirection as needed. However, the progress notes revealed ongoing episodes of delusions and hallucinations, such as seeing babies and cats in her room, believing her teddy bear was a real baby, and expressing a desire to leave the facility due to perceived intrusions. Despite these documented behaviors, the facility did not adequately address the underlying causes or adjust the care plan to better meet R11's needs. Interviews with staff, including registered nurses and nursing assistants, indicated that they received training on dementia and mental health conditions. However, there was uncertainty about R11's diagnoses, and the interventions identified by staff were limited to redirection, reassurance, and reorientation. The director of nursing emphasized the importance of understanding mental health conditions, yet the facility's actions did not reflect a comprehensive approach to managing R11's behavioral health needs. This lack of investigation and analysis contributed to the deficiency in providing necessary behavioral health care and services to R11.
Improper PPE Use in Covid-19 Isolation Room
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) when exiting a resident's room with a Covid-19 positive diagnosis. The resident, identified as R32, was severely cognitively impaired and had a diagnosis of Covid-19. On December 11, 2024, two staff members were observed outside R32's room donning isolation gowns and N-95 masks before entering. However, upon exiting, they were seen wearing surgical masks, having removed their N-95 masks inside the room and replaced them with surgical masks stored inside. This practice was contrary to the facility's policy and the Centers for Disease Control (CDC) guidelines, which state that all PPE except the respirator should be removed before exiting the room. Interviews with staff revealed a misunderstanding of the proper procedure for doffing PPE in an airborne isolation room. Nursing assistants reported being instructed by nurse managers to remove their N-95 masks inside the room, a practice confirmed by RN-B, who stated that staff were educated on PPE procedures during orientation and annually. However, the Director of Nursing (DON) clarified that N-95 masks should not be removed until outside the Covid-19 room to prevent exposure. The facility's policy, dated July 25, 2023, also directed staff to discard disposable respirators after exiting the resident room and performing hand hygiene, which was not followed in this instance.
Failure to Ensure Up-to-Date Immunization Records and Vaccine Education
Penalty
Summary
The facility failed to ensure that immunization records were up to date for two residents who were new admissions. Resident 13, who was over the age of 50 and had multiple diagnoses including hypertensive heart disease and atrial fibrillation, did not have a Minnesota Immunization Information Connection (MIIC) report, and the facility could not provide any immunization history. Similarly, Resident 40, also over the age of 50 with conditions such as spastic hemiplegia and nontraumatic intercerebral hemorrhage, lacked an MIIC report and immunization history. Interviews with registered nurses revealed uncertainty about the residents' vaccination status and whether follow-ups had been conducted. The facility also failed to educate and offer pneumococcal vaccines to residents upon admission. Resident 17, who had a history of cerebrovascular disease and diabetes mellitus, was eligible for a pneumococcal vaccine according to CDC guidelines but was not offered one. The registered nurse was unaware of the CDC's PneumoRecs VaxAdvisor and relied solely on the MIIC for vaccine status, without consulting the resident's provider about vaccine eligibility. The director of nursing expected staff to review CDC guidelines and offer vaccines appropriately, which was not done in this case. Additionally, the facility did not provide education or offer the influenza vaccine to three residents. Resident 11, with chronic heart failure and other conditions, had an outdated influenza vaccine record, and there was no documentation of the vaccine being offered to Residents 13 and 40. The facility could not provide evidence of education about the influenza vaccine or signed declinations from the residents or their representatives. The director of nursing was unsure of the process if a resident declined the vaccine, indicating a lack of clear procedures for handling vaccine refusals.
Failure to Educate and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents were educated on and offered COVID-19 vaccinations upon admission, as evidenced by the cases of three residents. Resident 11, who was admitted with chronic heart failure, hypertension, multidrug-resistant organism, diabetes mellitus, and depression, had a record of a COVID-19 vaccine received on 10/19/23. However, there was uncertainty from the staff regarding whether Resident 11 had been offered any vaccines upon admission. Resident 13, admitted with hypertensive heart disease, anxiety disorder, atrial fibrillation, and adult failure to thrive, had no immunization history available, and the staff assumed the resident was anti-vaccine without documented evidence of education or declination. Resident 40, admitted with spastic hemiplegia and nontraumatic intracerebral hemorrhage, also lacked an immunization history, and the staff was unsure if the resident or their representative had been followed up on regarding vaccination status. Interviews with the nursing staff revealed a lack of clarity and follow-through in documenting and offering COVID-19 vaccinations to these residents. RN-B was unaware of any immunization history for Resident 40 and unsure if any follow-up had occurred. RN-A assumed Resident 13 was anti-vaccine but had no documentation to support this belief. The Director of Nursing expected staff to identify a resident's vaccine status upon admission to ensure proper education and offering of vaccines, but this expectation was not met. The facility's policy required an immunization history to be taken upon admission and documented in the resident's medical record, with any unknown histories shared with the attending physician, but this process was not followed for the residents in question.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by staff, as evidenced by an incident involving a resident with severe cognitive impairments and multiple mental health disorders, including schizoaffective disorder, autism, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. The resident, who had a court-appointed guardian due to his inability to make decisions, was reported to have engaged in inappropriate sexual contact with a housekeeper. The resident's care plan noted a history of making inappropriate sexual comments and touching others inappropriately, with interventions in place to manage these behaviors. Despite these interventions, the resident reported to a registered nurse that he had a romantic relationship with a housekeeper, which included inappropriate touching. The nurse documented the incident but did not report it for investigation. The housekeeper confirmed the encounter, stating she was unaware of the prohibition against relationships with residents. An occupational therapy assistant assessed that the resident was not cognitively intact enough to consent to a relationship, highlighting the resident's vulnerability and the facility's failure to protect him from potential abuse.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with severe cognitive impairments, including schizoaffective disorder, autism, bipolar disorder, intellectual disabilities, Alzheimer's disease, dementia, and schizophrenia. The resident, who required extensive assistance with daily activities, informed a registered nurse (RN-A) that he had a romantic relationship with a housekeeper and that they had engaged in physical contact. Despite documenting the incident in the resident's medical record, RN-A did not report the allegation to the State Agency within the required two-hour timeframe. The housekeeper confirmed the resident's account, stating that she was unaware of the prohibition against relationships with residents until after the encounter. The facility's policy mandates that any suspected maltreatment be reported within two hours, a guideline reiterated by both RN-B and the director of nursing. The administrator also emphasized the importance of timely reporting. The failure to report the incident promptly constitutes a deficiency in the facility's adherence to its maltreatment reporting guidelines.
Failure to Provide Required Abuse Training
Penalty
Summary
The facility failed to ensure that required training on abuse, neglect, and exploitation was completed for a housekeeper, identified as H-A, whose personnel records were reviewed. During an interview, H-A stated she could not recall the last time she received such training. A review of her personnel file revealed that she had not undergone training on abuse, neglect, and exploitation since June 7, 2021. The Director of Nursing (DON) confirmed that all staff should receive this training upon hire, annually, and as events occur. The facility's Maltreatment Prohibition policy, reviewed on October 18, 2021, also directed that employees be trained on these policies and procedures during orientation and annually. However, the administrator acknowledged that H-A had not received the required education since 2021.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayshore Residence And Rehabilitation Center | 2.1 mi | — | 2 | 0 |
| Villa Marina Health And Rehab Ctr | 2.6 mi | — | 9 | 0 |
| Dove Healthcare - Superior | 3.7 mi | — | 2 | 0 |
| Twin Ports Health Services | 3.7 mi | — | 4 | 0 |
| Aftenro Home | 5.2 mi | — | 17 | 0 |
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