Franciscan Health Center
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Based on interviews and record review the facility failed to report an allegation of sexual assault within 2 hours to the State Agency (SA) for 2 of 3 clients (Resident R1, Resident R2) when reviewed for abuse. Findings include:Facility incident report dated 1/20/26 indicated on the morning of 1/20/26 at approximately 9:15 a.m., registered nurse (RN)-A reported Resident R1 came to the dining room to greet his wife (Resident R3) when an aide asked Resident R1 to move to passed him. Resident R1 moved and continued around the table to his wife (Resident R3) and came behind Resident R2 and groped her breasts without Resident R2's consent. Resident R1 was redirected to his room and was educated on the matter. Resident R1 had little to no remorse for the action he had made towards Resident R2. RN-A stated Resident R2 was aware the incident happened, but shortly after Resident R1 groped her she closed her eyes and showed no visual negative reaction or distress. Resident R2 was later interviewed by staff and had slight to no recall on the incident. Police were called and Resident R1 and Resident R2's responsible parties were notified. RN-A who reported the incident had not worked at the facility for a length of time and was not aware of the plans in place for Resident R1 and Resident R2, however the plan of care was followed. Facility reported incident to SA on 1/20/26 at 4:25 p.m.When interviewed on 1/29/26 at 2:14 p.m., social worker (SW) stated it was decided to make the report to SA after the investigation was mostly done and she was not aware to make the report first. SW agreed the incident was reported late and not within the two hours according to regulations and facility policy.Facility policy titled Maltreatment Reporting Guidelines reviewed date 11/26/24, indicated if alleged maltreatment occurs, report immediately, but not later than 2 hours after the allegation is made if the incident involved abuse, neglect, or financial exploitation, including injurie of unknown sources and misappropriation of VA property.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Franciscan Health Center in DULUTH, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DULUTH, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Franciscan Health Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.