St Francis Home: Grooming Care Failures Cited - MN
The woman, identified in inspection records as Resident 34, has Alzheimer's disease. She cannot brush her own teeth. She cannot ask someone to do it for her. She depends entirely on staff for every part of her daily care, including eating, dressing, and oral hygiene. Her care plan, updated less than a month before the inspection, documented that she needed total assistance from one staff member for oral care and that her own teeth were in good condition.
Federal inspectors observed the entire morning routine on June 9, 2026, starting at 7:06 a.m. Two nursing assistants worked together to get her up, use a stand-up lift, bring her to the bathroom, complete her personal cares, and transfer her to a wheelchair. By 7:16 a.m. she was dressed. By the time she was wheeled to the dining room at 8:12 a.m. to be fed breakfast, no one had touched her toothbrush.
The nursing assistant who led the morning routine, identified in the report as NA-A, confirmed it afterward. During an interview at 8:56 a.m., he told inspectors he had not offered or completed oral care and had not brushed her teeth. He said he had been working the evening shift until a few weeks earlier and was not used to morning routines. He also said most of the residents he cared for had dentures, so he was accustomed to rinsing and applying dentures in the morning rather than brushing natural teeth.
He knew it mattered. He told inspectors it was important to complete oral care so residents did not get cavities.
The second nursing assistant, NA-B, said his usual practice was to handle oral care in the evening.
Between the two of them, nobody had.
The resident's family had noticed. A family member told inspectors by phone the day before, on June 8, that they did not think staff routinely brushed the resident's teeth. "I think they do floss occasionally," the family member said, "but do not brush R34's teeth often enough." That conversation happened at 2:30 in the afternoon. The next morning, inspectors watched the concern play out in real time.
A registered nurse told inspectors that the expectation at the facility was for oral care and tooth brushing to be done during both morning and evening cares. She said oral care mattered to prevent infections and maintain good hygiene. The Director of Nursing was not available for an interview.
The facility's own grooming policy, though undated, stated that residents with natural teeth should have them brushed every morning, every evening, and as needed. Resident 34 had her own teeth. The morning shift came and went.
What makes the lapse harder to dismiss is the thoroughness of everything else that happened that morning. The two nursing assistants coordinated a mechanical lift, managed a transfer to the bathroom, completed perineal care, applied a brief and clothing, combed hair, used perfume. The room was cleaned. Soiled items were bagged and brought to the utility room. Hands were sanitized. The documentation of that morning's care, if it exists, would likely show a resident who received her morning routine.
Oral care takes two minutes. For a woman with Alzheimer's who cannot hold a toothbrush, cannot remind anyone, and cannot complain afterward, those two minutes depend entirely on whoever is in the room.
NA-A told inspectors that being observed completing cares was difficult. That detail sits in the record without elaboration.
The inspection found one deficiency, rated at the minimal harm level, affecting a small number of residents. St Francis Home, located at 2400 St Francis Drive in Breckenridge, is a small facility in a rural stretch of western Minnesota near the North Dakota border. The inspection was completed June 9, 2026.
The family member who called the day before the inspection did not know inspectors would be watching the next morning. They called because they had been watching for longer than that, and what they had seen, or hadn't seen, was enough to make them say something. Their word for what staff did with floss was "occasionally." Their word for brushing was "not often enough."
Resident 34 went to breakfast without her teeth brushed. Whether that was the exception or the pattern is a question the inspection record leaves open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Francis Home from 2026-06-09 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ST FRANCIS HOME in BRECKENRIDGE, MN was cited for violations during a health inspection on June 9, 2026.
The woman, identified in inspection records as Resident 34, has Alzheimer's disease.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.