Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Francis Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Alzheimer’s disease, and dependence on staff for oral hygiene did not receive routine tooth brushing during morning ADL care. Nursing assistants helped with bathing, dressing, perineal care, grooming, and transfer, but oral care was not offered or completed. A family member said staff did not routinely brush the resident’s teeth, and the RN stated oral care and brushing were expected with morning and evening cares per facility policy.
A resident with paraplegia, MS, an indwelling catheter, and a colostomy was on EBP for infection prevention, but two NAs provided extensive ADL care without wearing gowns and without sanitizing hands between glove changes. The NAs performed bathing, dressing, repositioning, transfer preparation, catheter emptying, and grooming while acknowledging they knew the resident was on EBP and that proper PPE and hand hygiene were required.
A resident with severe cognitive impairment, Parkinson’s disease, multiple comorbidities, high fall risk, and dependence for transfers and toileting was not receiving PT/OT or restorative therapy when nursing and the IDT independently changed his transfer method to a bariatric stand‑up lift without a prior therapy assessment. Despite documented increased tremors, weakness, difficulty aligning legs on the lift, and need for assist of two, therapy was not consulted before this change, and the resident subsequently experienced multiple transfer‑related incidents in which a sling loop slid off the lift and his legs gave out during a sit‑to‑stand transfer, requiring staff to lower him and use a full‑body lift. PT, OT, the DON, and the administrator later confirmed that therapy should determine appropriate lift type and safe transfer methods based on resident limitations, but this process was not followed when the resident’s condition declined and his transfer method was altered.
A resident with morbid obesity, hemiplegia, debility, and high fall risk, who depended on a bariatric stand-up lift (SUL) for transfers, was observed being transferred to and from the toilet by a NA without the SUL brakes engaged at multiple required points. The NA positioned the lift, applied the sling and belt, raised the resident from the wheelchair, moved her into the bathroom, lowered her onto the toilet, left her alone still attached to the lift, then later lifted and returned her to the wheelchair, all without consistently locking the brakes. The resident reported that some newer staff transferred her too fast, and the NA acknowledged she had been trained to use the brakes but did not do so with this resident because the resident disliked the brakes being on. Multiple staff and the Alliance stand assist lift manual confirmed that brakes were expected to be applied when the lift was positioned, while sling loops were attached, and while the resident was being lifted or lowered, and to remain locked when the resident was left attached to the lift, indicating the observed transfer did not follow manufacturer instructions or facility expectations.
A facility failed to administer medications according to standard practices for eight residents. A TMA was observed preparing medications in advance and not administering them immediately, contrary to facility policy. Medications were given in the dining room without observing residents taking them, and controlled medications were not signed out immediately. Interviews with staff confirmed these practices did not meet facility expectations.
The facility failed to assess and document the use of bed rails for nine residents, lacking comprehensive assessments, informed consent, and attempts at alternatives. Staff interviews revealed a lack of awareness and documentation, with bed rails often used to prevent falls despite policy stating they were for positioning. The Director of Nursing confirmed no assessments or informed consent were obtained, indicating a systemic issue in handling bed rail use.
In a LTC facility, a cook and nursing assistants were observed handling food and drinks unsanitarily, risking cross-contamination. The cook, C-A, used the same gloved hand to touch dietary cards and buns without sanitizing or changing gloves. Nursing assistants NA-C and NA-B touched the rims of glasses with bare hands while serving drinks. Both acknowledged their actions during interviews, and the facility's policy emphasizes using clean utensils and gloves to prevent contamination.
The facility failed to implement proper PPE practices for two residents with open wounds, leading to deficiencies in infection prevention and control. A resident with a pressure injury and another with a dehisced surgical wound were not provided with appropriate EBP, as staff were observed assisting them without wearing necessary gowns and gloves. The facility's policy on EBP was not followed, resulting in inadequate infection control measures.
Failure to Provide Routine Oral Care
Penalty
Summary
The facility failed to provide assistance with routine grooming cares, including oral care, for a resident who was dependent on staff for oral hygiene, personal hygiene, eating, and dressing. The resident had severe cognitive impairment with diagnoses including Alzheimer’s disease, anxiety, and depression. The care plan identified a self-care performance deficit related to Alzheimer’s disease and dementia, along with impaired balance and weakness, and specified that the resident required total assistance of one with oral care and had her own teeth in good condition. A family member stated staff did not routinely brush the resident’s teeth and believed flossing occurred only occasionally. During morning observation, nursing assistants assisted the resident with transfer, bathing, dressing, perineal care, grooming, and getting her ready for the day, but oral care was not offered or completed. One nursing assistant later verified he did not offer to complete oral care or brush the resident’s teeth and stated he was not used to morning cares after recently working evening shifts. Another nursing assistant stated his usual practice was to complete oral care in the evening. The RN stated oral care and brushing of teeth were expected with morning and evening cares, and the facility policy required residents with their own teeth to have them brushed every morning, every evening, and as needed.
Failure to Follow EBP During Resident Personal Care
Penalty
Summary
The facility failed to ensure staff completed hand hygiene and used proper PPE in accordance with CDC enhanced barrier precautions (EBP) while providing ADL care for a resident who was on EBP. The resident had paraplegia, multiple sclerosis, an indwelling catheter, and a colostomy, and was dependent on staff for personal hygiene, dressing, and transfers. The resident’s care plan identified a history of infections and specified EBP due to the indwelling catheter, and the resident’s door displayed an EBP sign with yellow gowns and gloves available in a hanging cabinet. During observation, two nursing assistants provided extensive personal care, including bathing, dressing, repositioning, transfer preparation, catheter emptying, and grooming. One nursing assistant entered the room, put on gloves, and performed care tasks such as removing the resident’s gown, checking the colostomy, washing the resident’s face, armpits, groin, and coccyx, applying barrier cream, and assisting with dressing and transfer. The second nursing assistant assisted with rolling the resident, helping with pants and sling placement, and handling urine documentation. Neither nursing assistant wore gowns during the personal care activities, and neither sanitized hands between glove changes. Both nursing assistants acknowledged they were aware the resident was on EBP and stated they did not follow proper PPE and hand hygiene practices during care. One nursing assistant stated a gown should have been worn and that hand hygiene was not performed between glove changes, while the other stated awareness of EBP but admitted not wearing proper PPE or sanitizing hands during glove changes. Nursing and administrative staff confirmed that staff were expected to wear gowns, gloves, and complete hand hygiene while providing personal care to residents on EBP, and the facility policy stated enhanced barrier precautions were to be used with residents who had wounds and/or indwelling medical devices such as a urinary catheter.
Failure to Obtain Therapy Assessment Before Changing Mechanical Lift Transfers for High‑Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain a comprehensive therapy assessment and to ensure treatment and care in accordance with professional standards of practice for a resident with complex medical and functional needs. The resident had severe cognitive impairment with disorganized thinking, Parkinson’s disease, non‑traumatic brain dysfunction, Alzheimer’s disease, dementia, depression, psychotic disorder, heart failure, arthritis, and unstable balance requiring human assistance. The MDS and fall risk assessment identified significant cognitive changes, high fall risk, limited ROM in an upper extremity, and dependence on staff for transfers, toileting, and lower body dressing, yet the resident was not receiving PT, OT, or restorative therapy at the time. Despite these documented deficits and high fall risk, the facility did not secure a therapy evaluation before changing the resident’s transfer method and lift type. From December through February, the resident experienced a decline in health, including acute renal failure, UTI, influenza A, dehydration, increased tremors, slurred speech, hallucinations, and increased weakness and shakiness. Nursing staff, without a therapy assessment, decided to move the resident to a bariatric stand‑up lift (SUL) based on nursing judgment when the resident became unable to stand. The DON and administrator later acknowledged that therapy should assess resident limitations and determine the safest transfer method, but therapy services were not on site from late November until early February. The RN reported that the IDT and nursing chose the bariatric SUL, which lacked a lower leg strap, and began transferring the resident with this device without prior PT/OT evaluation, even though the resident had increased tremors, difficulty aligning legs on the lift, and required assist of two for transfers. During this period, the resident experienced multiple transfer‑related incidents. On one occasion, a sling loop slid off the stand lift during transfer, and the resident was slowly lowered to the floor; a full body lift was then used to return the resident to a chair. On another occasion, while being transferred off the toilet with a Medline SUL, the resident’s legs gave out and he could no longer hold himself up; staff had to lower the lift and use a full body lift with three staff to move him to a recliner. Progress notes documented increased weakness and decline in mobility due to Parkinson’s, continued dependence on a SUL with assist of two, and the resident’s frustration with needing help for toileting and transfers. Interviews with PT, OT, the administrator, and the DON confirmed that therapy evaluation is expected to determine appropriate lift selection and safe transfer methods, and that this resident should have been assessed by therapy when his condition changed, but this did not occur prior to the nursing‑initiated changes in lift use that preceded the documented incidents.
Failure to Use Stand Lift Brakes per Manufacturer Instructions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow the manufacturer’s instructions and facility expectations for use of a bariatric stand-up lift (SUL) during transfers for one resident. The resident had intact cognition, morbid obesity, hemiplegia, osteoarthritis, debility, and muscle spasms, and was non-ambulatory, using a wheelchair for mobility. Her MDS and care plan identified high fall risk and required substantial/maximal assistance for transfers, with use of a bariatric SUL and staff assistance. A PT evaluation documented left hemiplegia, inability to use the left hand to hold the lift, limited left knee extension due to pain, and total dependence for transfers, though she could maintain position in the sling with her left arm extended laterally and use her lower extremities to attain a partial stand for transfers. During a direct observation of a transfer to and from the toilet using the bariatric SUL, a nursing assistant did not engage the lift’s brakes at multiple critical points, contrary to the Alliance Stand Assist Lifts user manual and facility staff expectations. The NA opened the legs of the lift, placed the sling and belt around the resident, and attached the sling loops without applying the brakes. The NA then raised the resident from the wheelchair while the resident held the hand grip only with the right hand, with the left arm positioned straight back and the resident’s body slouched, knees bent, and buttocks appearing to hang from the lift. The NA moved the lift into the bathroom, positioned the resident over the toilet, lowered her onto the toilet with her feet on the platform and still attached to the lift, and left the resident alone in the bathroom without engaging the brakes and with the resident remaining hooked to the lift. When the resident signaled she was finished, the NA returned and again operated the lift without consistently using the brakes. The NA lifted the resident from the toilet without opening the legs of the lift, pulled her away from the toilet, completed perineal care, and then moved the lift out of the bathroom. The NA opened the legs of the lift to clear the wheelchair and lowered the resident back into the wheelchair without engaging the brakes. At no point during the observed transfer did the NA ask the resident about using the brakes, and the resident did not request that the brakes be engaged. Interviews with the resident and multiple staff further described the circumstances leading to the deficiency. The resident reported that she relied on the stand lift for bathroom transfers and felt some newer staff lacked knowledge and transferred her too quickly, prompting her to ask them to slow down for her safety. The NA stated she had been educated to use the SUL brakes before hooking the resident to the lift and while lifting, and acknowledged that brakes should have been engaged before lowering the resident onto the toilet and while the resident remained attached to the lift. She reported that this resident did not like the brakes engaged and felt "trapped," and admitted she did not follow her training with this resident despite understanding that failure to use brakes could allow the lift to move and cause injury or a fall. Additional interviews with an RN, restorative aide, clinical engineering, the administrator, and the DON confirmed that facility expectations and training required brakes to be applied when the lift was positioned in front of the resident, while sling loops were attached, and while the resident was being lifted or lowered, with brakes released only when moving the lift from one location to another. Staff also stated that if a resident remained attached to the lift, such as while on the toilet, the brakes should remain locked, and staff were expected to remain in the room to help prevent an accident. The Alliance Stand Assist Lifts user manual specified that after opening the base to go around the chair, brakes on both rear casters should be applied before positioning the resident’s feet and knees, attaching sling straps, and pressing the up button, with brakes released only after the resident’s body had completely left the chair and the transfer was to proceed. The observed practice with this resident did not follow these manufacturer instructions or the facility’s stated expectations for safe lift use.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to the standard of practice for eight of the thirteen residents reviewed for medication administration. The trained medication aide (TMA) was observed preparing and administering medications in a manner that did not adhere to the facility's policies and procedures. Specifically, the TMA prepared medications in advance and placed them in the top drawer of the medication cart, rather than administering them immediately to the residents. This practice was contrary to the facility's policy, which required medications to be prepared and administered to one resident at a time to prevent medication errors. During the observation, the TMA was seen administering medications to residents in the dining room, rather than in their rooms, and did not always observe the residents taking their medications. The TMA also failed to sign out controlled medications in the controlled medication book immediately after administration, as required by the facility's policy. The TMA admitted to preparing medications in advance and storing them in the cart until the residents were located, which increased the risk of medication errors. Interviews with the registered nurse (RN), facility pharmacy consultant (PC), and director of nursing (DON) confirmed that the facility's expectations were not being met. The RN and PC emphasized the importance of following the five rights of medication administration and preparing medications for one resident at a time. The DON verified that the facility policy prohibited preparing medications ahead of time, and the failure to adhere to these guidelines was a significant deviation from the standard of practice.
Deficiency in Bed Rail Assessment and Documentation
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for nine residents, leading to a deficiency in care. The report highlights that the facility did not conduct comprehensive assessments, discuss the risks and benefits with residents or their representatives, obtain informed consent, or attempt alternatives before implementing bed rail use. This oversight was observed in multiple residents who had bed rails raised while in bed, despite their medical records lacking the necessary documentation and assessments. For instance, one resident with severe cognitive impairment and multiple diagnoses, including diabetes and depression, was observed with a bed rail raised without a comprehensive assessment or informed consent documented in their medical record. Similarly, another resident with severe cognitive impairment and dementia was found to have bed rails raised without documentation of who was informed about the risks and benefits. Interviews with staff revealed a lack of awareness and documentation regarding the use of bed rails, with some staff indicating that bed rails were used to prevent falls, despite the facility's policy stating they were for positioning purposes only. The facility's policy required a thorough assessment and informed consent before bed rail use, but this was not followed. The Director of Nursing confirmed that no assessments had been completed, and the facility had not discussed the risks versus benefits or obtained informed consent from residents or their representatives. The report indicates a systemic issue with the facility's handling of bed rail use, as evidenced by the lack of documentation and communication with residents and their families.
Sanitation Deficiencies in Food and Drink Service
Penalty
Summary
During dining observations in both the A wing and B wing dining rooms, food and drinks were not served in a sanitary manner, which had the potential to affect all residents dining there. On 7/15/24, a cook, identified as C-A, was observed setting up the steam table and serving lunch with gloves on. However, C-A repeatedly touched dietary cards with her right hand and then handled buns with both hands without sanitizing or changing gloves, leading to potential cross-contamination. This practice continued in both dining rooms, with C-A acknowledging during a telephone interview that she should not have touched the buns after handling the dietary cards, as the cards could have been contaminated. On 7/16/24, nursing assistants NA-C and NA-B were observed serving drinks in the A wing dining room while touching the rims of glasses and cups with their bare hands, which could lead to cross-contamination. Both NA-C and NA-B admitted during interviews that they were unaware of their actions and acknowledged the importance of not touching the rims to prevent contamination. The dietary manager and director of nursing confirmed that staff should not touch food or drink surfaces with bare hands to avoid cross-contamination, aligning with the facility's policy on food and nutrition services, which emphasizes the use of clean utensils and gloves when handling food.
Failure to Implement Proper PPE Practices for Infection Control
Penalty
Summary
The facility failed to implement proper donning and doffing of personal protective equipment (PPE) practices for two residents, R9 and R32, and did not ensure PPE was readily available for use to prevent the spread of infection. R9, who had moderate cognitive impairment and a stage two pressure injury, required extensive assistance for activities of daily living (ADLs). Despite the presence of an organizer with gowns, masks, and gloves outside R9's room, there was no sign indicating that R9 was on Enhanced Barrier Precautions (EBP). A nursing assistant (NA-E) was observed assisting R9 with transfers without wearing any PPE, and later confirmed she was unaware of the need to wear a gown and gloves during such activities. R32, who also had moderate cognitive impairment and a history of skin cancer, had an open wound on the left ear from a dehisced surgical excision. The care plan for R32 lacked any indication of a dressing being used, and there was no PPE located near R32's room. A registered nurse (RN-B) was observed assessing R32's wound without wearing a gown, and later acknowledged that EBP should have been implemented earlier. Another nursing assistant (NA-A) was seen assisting R32 with toileting while only wearing gloves, unaware of the requirement to wear a gown and gloves. The Director of Nursing (DON) confirmed that both R9 and R32 had open wounds with dressings and required EBP. The facility's policy indicated that EBP involves targeted gown and glove use during high-contact resident care activities, and PPE should be made available immediately near or outside the resident's room. However, the staff did not follow these guidelines, leading to the deficiency in infection prevention and control practices.
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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 Breckenridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Catherines Living Center | 1.2 mi | ★★★★★ | 6 | 0 |
| St Gerard's Community Of Care | 20.5 mi | ★★★★★ | 0 | 0 |
| Mn Veterans Home Fergus Falls | 24.6 mi | ★★★★★ | 8 | 1 |
| Lb Broen Home | 24.9 mi | ★★★★★ | 5 | 0 |
| Pioneer Care Center | 25.2 mi | ★★★★★ | 7 | 0 |
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