Inspection Reports for
St Andrew’s at Francis Place

The complaint was substantiated. Resident #24 reported being upset about being made to get up and described the transfer as rough, resulting in a skin tear. The CNA was instructed by nursing staff to get the resident up despite refusal. The facility investigation confirmed the incident and injury but did not initially recognize the resident rights violation. Transfer training was provided to some staff after the incident, but not all staff received in-service on resident rights.

The facility failed to ensure the resident's right to self-determination was respected when CNA D transferred Resident #24 out of bed against their wishes, causing a large skin tear requiring hospital treatment. The facility investigated the incident, provided transfer training to some staff, but did not fully address resident rights or provide in-service training on resident rights to all staff.

The facility failed to ensure that residents designated for the walk to dine program received the restorative service of being walked to and from the dining room. Interviews and observations confirmed that staff did not consistently provide this service, despite policies and care plans indicating it should be done.

The facility failed to ensure the fire alarm panel was secured and accessible only to authorized personnel, lacked complete documentation for electrical receptacle testing, and improperly stored oxygen cylinders. These deficiencies posed potential risks to all occupants.

The facility failed to accommodate resident preferences regarding room arrangement and siderail use, did not follow up on third party liability forms for expired residents, had inconsistent and outdated code status documentation, failed to update care plans after significant changes, did not follow physician orders for weights and hospice care, failed to implement 14-day stop dates for PRN psychotropic medications, had unclean kitchen equipment and expired food, incomplete resident treatment documentation, lapses in infection control practices including improper PPE use and catheter care, and lacked documentation of required nurse aide education hours.

The facility was found noncompliant with several federal regulations including reasonable accommodations for residents' needs and preferences, infection control, clinical records accuracy, food safety, advance directives, resident rights, and care plan revisions. Deficiencies were cited with varying severity levels, and a plan of correction was submitted.

The investigation was complaint-driven, focusing on resident rights to caregiver gender preference, treatment of skin tears, and fall management including neurological checks and documentation.

The facility failed to respect a resident's preference for female caregivers, improperly managed a resident's skin tear treatment without physician orders, and did not follow fall policy including neurological checks and fall risk assessments for multiple residents.

The facility failed to ensure residents received ordered treatments and care according to professional standards, including skin care treatments for six sampled residents. The facility also failed to follow fall policy by not completing neurological checks and fall interventions for three residents after falls.

The facility failed to ensure residents received treatment and care in accordance with professional standards, including inadequate documentation of ordered skin treatments and failure to respect resident rights regarding caregiver preferences. Deficiencies were noted in care for residents with gastrostomy tubes, suprapubic catheters, and skin ulcers.

Complaint involved allegations of misappropriation/diversion of controlled substances by Licensed Practical Nurse (LPN) B for 11 residents. The complaint was substantiated with evidence including video footage, medication administration records, and narcotic sign out sheets. LPN B voluntarily resigned. The local police department and Missouri Board of Nursing were notified. Additional complaints involved failure to report timely and failure to follow care protocols.

The facility failed to prevent misappropriation/diversion of controlled substances by a nurse, failed to timely report allegations to authorities, allowed continued work of the accused nurse during investigation, and failed to follow proper investigation and documentation procedures. Additionally, the facility failed to follow a nurse practitioner's order for a stat x-ray after a resident fall and failed to provide two-person care as required, resulting in a resident fall.

The facility failed to provide timely transfer notices for hospital transfers, did not ensure PASARR screenings for residents with mental disorders or intellectual disabilities, and failed to meet professional standards in care plans related to insulin administration. Additionally, the facility did not submit required staffing data on time.

The facility failed to update its emergency disaster preparedness guide annually and did not have a comprehensive emergency preparedness plan including emergency generator procedures. The facility also failed to maintain kitchen range hood cleaning, fire alarm inspections, portable fire extinguisher maintenance, smoke barrier integrity, and electrical wiring compliance.

The facility was found to have deficiencies related to failure to notify the resident's physician of a significant change in condition, inadequate treatment and prevention of pressure ulcers, and insufficient pain management. The facility implemented corrective actions and submitted a plan of correction.

The investigation was triggered by complaints regarding failure to notify the physician of a resident's pressure ulcer and failure to provide appropriate wound care and pain management. The resident developed a severe pressure ulcer that was not properly treated, leading to hospitalization and death from septic shock. The facility was found to have failed in notification, documentation, wound care, and pain assessment.

The facility failed to notify the physician of a resident's deteriorating pressure ulcer, failed to provide appropriate wound care and pain management, and did not conduct timely pain assessments. The resident developed a severe pressure ulcer that led to hospitalization and death due to septic shock. The facility was found to have inadequate wound monitoring, documentation, and communication with the physician.

The complaint involved an allegation that a Certified Nurse Aide (CNA) was a possible perpetrator of taking a resident's checkbook and bank statements. The investigation included interviews with the resident, staff, and review of surveillance and documentation. The allegation was substantiated by the facility's failure to prevent and properly respond to the incident.

The facility failed to develop and implement adequate abuse and neglect policies and procedures, as evidenced by the alleged misappropriation of a resident's property by a CNA. The investigation revealed missing resident financial documents and insufficient staff response to the incident.

The complaint investigation was substantiated as the facility failed to report and investigate alleged neglect and failed to provide adequate nursing care to Resident #1 who suffered serious injuries from an unwitnessed fall.

The facility failed to report potential neglect to the Department of Health and Senior Services timely and did not perform or document required post-fall assessments including pain evaluations, neurological assessments, and vital signs. The resident sustained multiple injuries including facial fractures and a cerebral hemorrhage, and the facility failed to provide acceptable nursing care and timely reporting.

The facility was found deficient in meeting professional standards for comprehensive care plans, psychotropic medication management, and food safety requirements. Specific issues included lack of physician orders for oxygen, incomplete weekly skin assessments, failure to re-evaluate PRN psychotropic medications after 14 days, and improper ice machine drain installation.

The facility failed to meet several Life Safety Code requirements including self-closing doors to hazardous areas, fire alarm system access control, sprinkler system maintenance, fire drills completion, and proper oxygen cylinder storage. These deficiencies had the potential to affect building occupants in multiple smoke compartments.

The investigation was complaint-driven, focusing on issues with oxygen administration, skin assessments, psychotropic medication management, and food safety. The findings indicated minimal harm with few residents affected.

The facility failed to obtain physician's orders for oxygen administration and did not complete weekly skin assessments as ordered. Psychotropic medications were not re-evaluated after 14 days of use as required. The ice machine lacked an air gap to prevent backflow contamination.

The survey was complaint-related focusing on COVID-19 infection prevention and control practices. The complaint was substantiated as deficiencies were found in PPE use, isolation procedures, and infection control policies.

The facility failed to fully comply with infection prevention and control requirements, including improper use of personal protective equipment (PPE), inadequate signage and isolation procedures, and lapses in hand hygiene and cleaning protocols. Several residents and staff were observed not following COVID-19 precautions, and infection control policies were not consistently implemented.

The complaint investigation was substantiated. The facility was found to have failed in protecting residents from abuse, neglect, and mistreatment, including sexual abuse. The investigation revealed multiple incidents involving residents and staff, inadequate staff response, and failure to follow policies and report allegations timely.

The facility failed to issue required Medicaid notices, failed to protect residents from abuse and neglect including sexual abuse, and failed to properly investigate and document allegations of abuse. Deficiencies were found in care planning, supervision, and staff training related to resident safety and abuse prevention.

The facility failed to maintain fire extinguishers according to NFPA standards and did not properly maintain oxygen cylinder storage in compliance with NFPA code. These deficiencies potentially affected all residents and staff.

The facility was found deficient in multiple areas including resident rights, financial security of personal funds, activities of daily living care, and infection prevention and control. Several residents were observed to have inadequate privacy and care, and the facility failed to maintain an approved surety bond for resident funds.

The facility failed to ensure 100% annual testing of the fire alarm system, maintain quarterly sprinkler system inspections, and maintain smoke barrier walls with proper fire resistance and closure of fire dampers. These deficiencies had the potential to affect all occupants in the building.