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Complaint Investigation

Franciscan Health Center

January 29, 2026 · Duluth, MN · 3910 Minnesota Avenue
Citations 1
CMS Rating 1/5
Beds 47
Provider ID 245258
Healthcare Facility
Franciscan Health Center
Duluth, MN  ·  View full profile →
Inspection Summary

Franciscan Health Center in DULUTH, MN — inspection on January 29, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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 (R1, 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 R1 came to the dining room to greet his wife (R3) when an aide asked R1 to move to passed him. R1 moved and continued around the table to his wife (R3) and came behind R2 and groped her breasts without R2's consent. R1 was redirected to his room and was educated on the matter. R1 had little to no remorse for the action he had made towards R2. RN-A stated R2 was aware the incident happened, but shortly after R1 groped her she closed her eyes and showed no visual negative reaction or distress. R2 was later interviewed by staff and had slight to no recall on the incident.

Police were called and R1 and 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 R1 and 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

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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.


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