Inspection Reports for
St Francois Manor
1180 OLD JACKSON RD, FARMINGTON, MO, 63640-3428
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
136% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
11% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 17
Deficiencies: 3
Date: Jan 15, 2026
Visit Reason
The inspection was conducted to identify deficiencies related to oxygen storage, furniture and equipment maintenance, and wall/ceiling covering conditions at St. Francois Manor.
Findings
The facility failed to display proper oxygen warning signage, maintain kitchen equipment in good condition, and ensure ceilings were sealed and cleanable. These deficiencies had the potential to affect all residents, with a census of 17.
Deficiencies (3)
19 CSR 30-86.022(17) Oxygen Storage Requirements: The facility failed to display proper oxygen warning signage on two resident room doors where oxygen concentrators were in use.
19 CSR 30-86.032(22) Furniture/Equip, Provide Comfort & Safety: The facility failed to maintain kitchen equipment in good condition, including a gas stove with burners covered in black, greasy, charred substance and a non-working double oven.
19 CSR 30-87.020(16) Wall/Ceiling Covering-Sealed & Cleanable: The facility failed to ensure ceilings were kept sealed and in good repair, with 13 ceiling tiles displaced exposing pipes and wiring in resident hallways.
Report Facts
Deficiencies cited: 3
Resident census: 17
Audit duration: 4
Inspection frequency: 30
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Nov 17, 2025
Visit Reason
The inspection was conducted based on Complaint #2616588 regarding failure to notify a resident's physician or guardian after a change in condition and failure to follow physician's orders related to urinary catheter care for Resident #1.
Complaint Details
Complaint #2616588 involved substantiated issues including failure to notify physician and guardian of condition change and failure to follow physician's orders for catheter care and follow-up.
Findings
The facility failed to notify the physician and guardian after Resident #1 pulled out his/her urinary catheter and failed to follow physician's orders regarding catheter care and follow-up appointments. Staff did not document reinsertion of the catheter or monitor urine output as ordered.
Deficiencies (2)
Failed to notify resident's physician or guardian after a change in condition when urinary catheter was pulled out.
Failed to follow physician's orders for urinary catheter care, including lack of follow-up appointments and inadequate monitoring of urine output.
Report Facts
Residents Affected: 1
Facility Census: 89
Catheter size: 18
Balloon size: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding knowledge of straight catheterization orders |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about resident's catheter care and monitoring |
| Nurse Aide A | Nurse Aide | Interviewed about monitoring and documentation of urine output |
| Administrator | Administrator | Interviewed about expectations for following physician orders and scheduling follow-up appointments |
| Director of Nursing | Director of Nursing | Interviewed about expectations for notifying physician and guardian and following physician orders |
Inspection Report
Routine
Census: 78
Deficiencies: 7
Date: Jun 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including posting of hotline information, resident safety related to bed rails, nurse staffing, medication labeling, food storage, and maintenance of bed equipment.
Findings
The facility was found deficient in multiple areas including failure to post required hotline information, inadequate assessment and maintenance of bed rails for residents, lack of RN coverage for some days, failure to post nurse staffing data daily, expired medications present, improper food storage and temperature control, and lack of regular inspections for bed frames and side rails.
Deficiencies (7)
Failed to post required telephone number to the Department of Health and Senior Services hotline and State Survey Agency information in a form accessible to residents.
Failed to assess residents for safety risk related to bed rails and to provide ongoing monitoring and maintenance of beds with side rails.
Failed to provide a Registered Nurse on duty for eight consecutive hours per day, seven days a week.
Failed to post nurse staffing information daily with all required components in a clear and readable format.
Failed to ensure medications and biologicals were labeled in accordance with accepted professional principles; expired medications found.
Failed to store and distribute food under sanitary conditions; multiple food items not dated and freezer temperatures consistently above required range.
Failed to conduct regular inspections of all bed frames, mattresses, and side rails for safety and possible entrapment.
Report Facts
Facility census: 78
Days without RN coverage: 2
Expired medication count: 21
Expired medication count: 8
Freezer temperature out of range: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding posting hotline information, RN coverage expectations, nurse staffing posting, medication expiration, and freezer temperature logs | |
| Director of Nursing | DON | Interviewed regarding side rail assessments, nurse staffing posting, medication expiration, and freezer temperature logs |
| Maintenance Director | Interviewed regarding maintenance and inspection of side rails and walk-in freezer issues | |
| Registered Nurse B | RN | Interviewed regarding medication expiration responsibilities and side rail assessments |
| Certified Medication Technician A | CMT | Interviewed regarding pharmacy medication expiration checks |
| Restorative Aide C | Interviewed regarding side rail assessments and recommendations | |
| Assistant Director of Nursing | ADON | Interviewed regarding side rail ordering and assessments |
| Dietary Manager | DM | Interviewed regarding food storage, freezer issues, and temperature logs |
| MDS Coordinator | Interviewed regarding side rail assessments |
Inspection Report
Plan of Correction
Census: 17
Deficiencies: 4
Date: Mar 4, 2025
Visit Reason
The document is a plan of correction submitted in response to a deficiency statement from a state inspection conducted on 03/04/2025 at St Francois Manor.
Findings
The facility failed to maintain resident rooms, carpeting, walls, ceilings, doors, windows, and light fixtures in a clean, orderly, and well-maintained condition. Multiple observations and interviews confirmed issues such as dust, dirt, stains, clutter, and maintenance delays affecting resident areas.
Deficiencies (4)
19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily. The facility failed to ensure resident rooms were cleaned daily and orderly, with dust, dirt, clutter, and stains observed in multiple resident rooms.
19 CSR 30-87.020(13) Carpeting. The facility failed to maintain carpets in clean and good repair, with worn and stained carpets observed in hallways and resident rooms.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean. The facility failed to keep walls, ceilings, doors, and windows clean and in good repair, with visible dirt and damage noted.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable. The facility failed to maintain light fixtures, vent covers, and similar equipment in a clean and good repair condition, with broken and dirty fixtures observed.
Report Facts
Facility census: 17
Inspection Report
Routine
Census: 80
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to ensure the nursing facility met professional standards of quality, specifically reviewing medication administration practices.
Findings
The facility failed to follow physician's orders regarding medication administration for one resident, who missed 18 doses of clonazepam out of 28 opportunities. The facility lacked a proper system for ordering and tracking medications, leading to delays and missed doses.
Deficiencies (1)
Failed to follow physician's orders regarding medication administration for one resident, resulting in missed doses of clonazepam.
Report Facts
Missed medication doses: 18
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Discovered resident was out of medication and called Psychiatric Nurse Practitioner |
| CMT B | Certified Medication Technician | Noticed resident was out of clonazepam and informed LPN A |
| Director of Nurses | Director of Nurses | Interviewed about medication ordering and tracking procedures |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Ordered medication and communicated with pharmacy about lost order |
| Administrator | Administrator | Interviewed regarding expectations for notification of low medications |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 2
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, specifically regarding medication administration and care plans for residents.
Findings
The facility failed to follow physician's orders for medication administration for one resident, resulting in multiple missed doses of clonazepam. The facility lacked a system to ensure timely ordering and administration of medications, leading to resident safety concerns.
Deficiencies (2)
F 658: The facility failed to meet professional standards of quality by not following physician's orders for medication for one resident, resulting in multiple missed doses of clonazepam. There was no system in place to ensure medications were ordered and administered timely.
A4075: Each resident did not receive personal attention and nursing care consistent with their condition, as evidenced by the medication administration deficiencies noted in F658.
Report Facts
Missed medication doses: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Willey Malone | Administrator | Signed the plan of correction and involved in interviews regarding medication administration issues. |
Inspection Report
Routine
Census: 77
Deficiencies: 5
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident privacy, environment safety and cleanliness, trauma-informed care, medication management, and pharmaceutical services at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide privacy curtains for residents, inadequate environmental cleanliness and maintenance, failure to assess and address PTSD triggers for residents, missed medication administrations and refill delays, and storage of expired medications. The deficiencies were generally of minimal harm and affected a few residents.
Deficiencies (5)
Failed to provide a privacy curtain to maintain privacy for two residents (Resident #3 and #10).
Failed to provide a safe, clean, comfortable, and homelike environment; multiple environmental issues observed including holes in walls, peeling baseboards, sticky substances on floors, and unclean bathroom vents.
Failed to identify, assess, and provide supportive interventions for six residents with PTSD; no trauma assessments or personalized triggers addressed in care plans.
Failed to ensure medications were accurately administered, documented, disposed of, and reconciled for two residents; multiple missed doses and refill delays noted.
Failed to ensure drugs and biologicals were labeled and stored properly; expired medications found in storage.
Report Facts
Residents affected: 2
Residents affected: 6
Missed medication doses: 5
Missed medication doses: 1
Missed medication doses: 7
Missed medication doses: 7
Facility census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Interviewed regarding responsibility for privacy curtains | |
| Maintenance director | Interviewed regarding responsibility for privacy curtains | |
| Administrator | Interviewed regarding expectations for resident privacy and building maintenance | |
| Director of Nursing | DON | Interviewed regarding environmental issues, medication management, and PTSD assessments |
| Certified Nurse's Assistant B | CNA | Interviewed regarding awareness of resident interventions related to PTSD triggers |
| Registered Nurse C | RN | Interviewed regarding care plan requirements for PTSD |
| Interim Social Services Designee | SSD | Interviewed regarding PTSD assessments at admission |
| Licensed Practical Nurse I | LPN | Interviewed regarding medication availability for residents |
| Certified Medication Technician E | CMT | Interviewed regarding medication ordering and refill process |
| Pharmacist H | Interviewed regarding medication refill requests and pharmacy communication | |
| Licensed Practical Nurse D | LPN | Interviewed regarding medication storage and pharmacy visits |
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 10
Date: Jun 13, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for St Francois Manor nursing facility.
Findings
The facility was found deficient in multiple areas including privacy protections, safe and homelike environment, trauma-informed care, pharmacy services, medication management, and labeling/storage of drugs. Deficiencies affected resident privacy, environmental conditions, trauma care, and medication safety.
Deficiencies (10)
F583 Privacy and confidentiality were not maintained as two residents lacked privacy curtains between beds in their semi-private rooms.
F584 The facility failed to provide a safe, clean, comfortable, and homelike environment, with issues such as holes in walls, missing closet doors, dirty vents, and malfunctioning doors observed.
F699 The facility did not provide trauma-informed care by failing to identify, assess, and provide supportive interventions for six residents with PTSD diagnoses.
F755 The facility failed to provide routine and emergency pharmaceutical services, including timely ordering and administration of medications for residents.
F761 The facility failed to ensure all drugs and biologics were labeled and stored properly, including expired medications not destroyed and unsecured medication storage.
A3038 The facility failed to maintain furniture and equipment in good condition to ensure resident comfort and safety.
A3039 The facility failed to maintain rooms neat, orderly, and cleaned daily.
A4055 The facility failed to maintain a safe and effective medication system.
A4067 The facility failed to destroy non-unit doses and controlled substances within 30 days as required.
A8029 The facility failed to maintain confidentiality of resident medical and personal information.
Report Facts
Facility census: 77
Residents sampled: 18
Residents with PTSD diagnosis assessed: 6
Medication doses missed: 40
Expired medication destruction frequency: 2
Inspection Report
Life Safety
Census: 77
Deficiencies: 2
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain hazardous areas free of penetrations and did not maintain sprinkler heads in proper functioning condition. Observations included unsealed pipe penetrations and sprinkler heads covered in dust and grease, potentially affecting all residents and staff.
Deficiencies (2)
K321 Hazardous areas are not protected by a fire barrier or automatic fire extinguishing system as required, with unsealed pipe penetrations in the men's unit hot water heater closet.
K353 Sprinkler system maintenance and testing requirements were not met; sprinkler heads were found covered in dust and grease in the kitchen area.
Report Facts
Facility census: 77
Inspection Report
Life Safety
Census: 16
Deficiencies: 1
Date: Jan 24, 2024
Visit Reason
The inspection was conducted due to a fire alarm system being out of service for more than four hours, requiring evaluation of compliance with fire safety regulations.
Findings
The facility failed to implement an approved fire watch and notify the appropriate authorities when the fire alarm system was out of service for over four hours. The fire alarm panel showed trouble and silence signals, and staff were unaware of the issue or how to respond properly.
Deficiencies (1)
19 CSR 30-86.022(8)(H) Fire Alarm System Out of Service > than 4hrs. The facility failed to implement an approved fire watch and notify the department and local fire authority when the fire alarm system was out of service for more than four hours. Staff were unaware of the fire panel trouble and did not follow proper procedures.
Report Facts
Facility census: 16
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at St Francois Manor.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint investigation on 8/29/23.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation. No deficiencies were cited as a result of this onsite visit.
Inspection Report
Plan of Correction
Census: 24
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The visit was conducted to assess compliance with regulations regarding fresh water availability to residents at St Francois Manor.
Findings
The facility failed to maintain fresh water availability to residents at all times, with observations noting non-functioning water fountains and lack of water or drinks in the dining area. The deficiency was classified as Class III and had the potential to affect all residents.
Deficiencies (1)
19 CSR 30-86.052(4) Fresh Water: The facility failed to maintain fresh water available to residents at all times, evidenced by non-functioning water fountains and absence of water or drinks in the dining room.
Inspection Report
Routine
Census: 71
Deficiencies: 4
Date: Jan 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to the facility's environment, resident care, food safety, and waste disposal.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment, inadequate physical therapy services for a resident, unsanitary food storage and preparation conditions, and improper waste disposal practices. These deficiencies had the potential to affect all or many residents with minimal harm.
Deficiencies (4)
Failure to maintain a safe, clean, comfortable and homelike environment with grime on doors, unclean walls, and maintenance issues.
Failure to provide appropriate physical therapy services to maintain or improve resident function.
Failure to store and distribute food under sanitary conditions, including food on the floor, grime on kitchen equipment, and ice build-up in refrigeration.
Failure to properly dispose of garbage with dumpster lids left open on multiple occasions.
Report Facts
Facility census: 71
Residents affected: 1
Residents affected: Few
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #72 | Resident | Named in physical therapy deficiency for not receiving ordered therapy |
| Resident #13 | Resident | Reported maintenance issues and roof leak |
| CNA E | Certified Nursing Assistant | Reported on maintenance and wall damage |
| Maintenance Director | Maintenance Director | Described repair process and priorities |
| Administrator | Facility Administrator | Provided information on housekeeping routines and order processing |
| Director of Nursing | Director of Nursing | Discussed physician order processing issues |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Discussed order double-checking process |
| Certified Nurse Aid (CNA) B | Certified Nurse Aid | Reported resident therapy status |
| MDS Coordinator | MDS Coordinator | Discussed order double-checking process |
| Dietary Aide C | Dietary Aide | Reported cleaning duties and dumpster lid expectations |
| Dietary Aide D | Dietary Aide | Reported cleaning duties and dumpster lid expectations |
| Dietary Manager | Dietary Manager | Discussed kitchen cleanliness and maintenance issues |
| Registered Dietician | Registered Dietician | Discussed food storage and kitchen cleanliness expectations |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 4
Date: Jan 12, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for St. Francois Manor nursing facility.
Findings
The facility failed to maintain a safe, clean, and comfortable environment, with multiple observations of grime and maintenance issues. Deficiencies were also found in mobility services, food safety, and waste disposal practices, potentially affecting all residents.
Deficiencies (4)
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a safe, clean, and comfortable environment as evidenced by grime on multiple doors, peeling paint, drywall damage, and slow maintenance response. The facility census was 71.
F688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide appropriate treatment and services to maintain or improve mobility for Resident #72, with no physical therapy received despite physician orders.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to store and distribute food under sanitary conditions, increasing risk of cross-contamination and food-borne illness. The facility census was 71.
F814 Dispose Garbage and Refuse Properly. The facility failed to ensure garbage dumpsters and trash receptacles were covered and properly maintained for four days of observation. The facility census was 71.
Report Facts
Facility census: 71
Sampled residents: 22
Resident referenced: 72
Inspection Report
Life Safety
Census: 71
Deficiencies: 2
Date: Jan 12, 2023
Visit Reason
The inspection was conducted as an Emergency Preparedness survey and Life Safety Code survey to assess compliance with fire safety and smoking regulations.
Findings
The facility failed to maintain self-closing doors in exit passageways and failed to maintain smoking areas properly, including overflowing ash-cans. These deficiencies potentially affected all residents and staff.
Deficiencies (2)
K223 Doors with Self-Closing Devices: The facility failed to maintain required self-closing doors in exit passageways, stairway enclosures, or hazardous areas. The door to the hot water heater closet in the kitchen lacked automatic closure.
K741 Smoking Regulations: The facility failed to maintain smoking areas as required, with resident smoking ash-cans overflowing with cigarette butts and combustible trash.
Report Facts
Facility census: 71
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 8, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on 7/8/2022 in addition to a complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 23
Deficiencies: 4
Date: Jun 28, 2022
Visit Reason
The inspection was conducted to assess compliance with fire safety, emergency lighting, toxic material storage, and ice machine sanitation regulations at St Francois Manor.
Findings
The facility failed to maintain fire extinguishers, emergency lighting, and proper storage of toxic materials, and did not provide an air gap for the ice machine drain pipe. These deficiencies had the potential to affect all residents.
Deficiencies (4)
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to properly maintain fire extinguishers and provide documentation of monthly pressure checks. No policy was provided for maintenance of fire extinguishers.
19 CSR 30-86.022(12)(B) Emergency Lighting - Power Source. The facility failed to maintain emergency lighting in good repair; multiple emergency lights failed to function during testing. No policy was provided for maintenance of emergency lighting.
19 CSR 30-87.020(5) Toxic Material Storage. The facility failed to ensure hazardous chemicals were stored securely and inaccessible to residents; housekeeping closet door was unlocked and chemicals were accessible.
19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap. The facility failed to provide an air gap for the ice machine drain pipe to prevent contamination. No policy was provided for maintenance of drain pipes or air gap.
Report Facts
Facility census: 23
Inspection Report
Routine
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 1
Date: May 27, 2020
Visit Reason
A COVID-19 focused abbreviated emergency preparedness survey was conducted to assess compliance with infection prevention and control requirements related to COVID-19.
Findings
The facility was found to be out of compliance with infection prevention and control requirements, including failure to maintain social distancing, improper use of PPE, inadequate cleaning and disinfecting procedures, and poor management of linens and common areas.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program to prevent the spread of COVID-19, including inadequate social distancing, improper use of PPE, and insufficient cleaning and disinfecting of dining tables and common areas.
Report Facts
Facility census: 88
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 15
Date: Jan 23, 2020
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for St. Francois Manor nursing facility.
Findings
The facility was found to have multiple deficiencies including environmental maintenance issues, failure to notify appropriate authorities of significant resident changes, inadequate baseline and comprehensive care plans, insufficient staff training, infection control lapses, and medication administration errors. The facility submitted a plan of correction addressing these deficiencies.
Deficiencies (15)
F584 Safe Environment: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance issues affecting multiple residents.
F646 MD/ID Significant Change Notification: The facility failed to notify the appropriate state-designated authority for a resident's significant change in mental or physical condition.
F655 Baseline Care Plan: The facility failed to develop and implement baseline care plans with specific interventions and provide written summaries to residents or representatives.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes.
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with interdisciplinary team involvement and resident participation.
F680 Qualifications of Activity Professional: The facility failed to have a qualified activities professional directing the activities program.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment was free of accident hazards and provide adequate supervision to prevent accidents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide adequate catheter care and maintain continence services.
F698 Dialysis: The facility failed to establish a written agreement with the dialysis center and ensure coordination of care for residents receiving dialysis.
F741 Sufficient/Competent Staff-Behav Health Needs: The facility failed to ensure certified nursing assistants were trained annually on dementia care.
F744 Treatment/Service for Dementia: The facility failed to provide individualized interventions for residents diagnosed with Alzheimer's dementia.
F755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to ensure accurate medication administration and proper narcotic count procedures.
F868 QAA Committee: The facility failed to maintain a quality assessment and assurance committee with required members.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program.
F881 Antibiotic Stewardship Program: The facility failed to establish an antibiotic stewardship program with protocols and monitoring.
Report Facts
Facility census: 86
Deficiencies cited: 15
Inspection Report
Life Safety
Census: 86
Deficiencies: 6
Date: Jan 21, 2020
Visit Reason
The inspection was a life safety code survey to assess compliance with fire safety regulations and related provisions.
Findings
The facility failed to maintain adequate cigarette disposal cans, prohibited combustible decorations, and maintain facility wiring free of temporary or unsafe extension cords. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K741 Smoking Regulations: The facility failed to maintain adequate cigarette disposal cans, with a cigarette bin outside 400 hall half full and uncovered. This affected all residents and staff.
K753 Combustible Decorations: The facility failed to maintain the facility free of combustible decorations, including candles observed in therapy and medical records rooms. This affected all residents and staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain facility wiring free of temporary wiring and improper use of power strips in nursing and medical records offices. This affected all residents and staff.
A2009 Combustible Materials, Unnecessary: The storage of unnecessary combustible materials in the building presented a fire hazard.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Designated smoking areas lacked proper ashtrays of noncombustible material and safe design.
A3037 Extension Cords/Duplex Receptacles: Extension cords were used improperly and located where subject to physical damage.
Report Facts
Facility census: 86
Deficiencies cited: 6
Inspection Report
Plan of Correction
Census: 20
Deficiencies: 1
Date: Dec 4, 2019
Visit Reason
The visit was conducted to identify and document deficiencies related to ice machine contamination and air gap issues at St Francois Manor.
Findings
The facility failed to provide an air gap for the ice machine drain pipe to prevent contamination, with observed buildup and potential risk to residents. The Administrator committed to cleaning and maintaining the ice machine drain pipes to correct the deficiency.
Deficiencies (1)
19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap. The facility failed to provide an air gap for the ice machine drain pipe to protect against contamination, with observed buildup in the drain pipe and floor drain.
Report Facts
Facility census: 20
Inspection Report
Plan of Correction
Census: 92
Deficiencies: 2
Date: Oct 31, 2019
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding the facility's failure to assess and notify the physician of a resident's fever and condition change.
Findings
The facility failed to meet professional standards by not properly assessing and notifying the physician about a resident's fever and condition change. Interviews and record reviews showed documentation and communication lapses among nursing staff.
Deficiencies (2)
F658: The facility failed to assess a resident with fever and notify the physician as required by the comprehensive care plan. Nursing staff did not document elevated temperatures or notify the physician promptly.
A4074: The regulation requiring personal attention and nursing care consistent with current acceptable nursing practice was not met, as referenced to F658. This deficiency is classified as Class II.
Report Facts
Census: 92
Inspection Report
Annual Inspection
Census: 95
Deficiencies: 11
Date: Apr 18, 2019
Visit Reason
Annual survey conducted to assess compliance with federal regulations for St Francois Manor nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure accuracy of residents' advance directives, failure to issue required Medicaid notices, failure to check CNA registry for new hires, failure to develop baseline care plans within 48 hours, failure to implement individualized comprehensive care plans, failure to ensure proper discharge summaries, and improper storage and labeling of drugs and biologicals.
Deficiencies (11)
F578: The facility failed to ensure accuracy of residents' advance directives regarding resuscitation status for two residents.
F582: The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to two residents when benefits were not exhausted.
F606: The facility failed to check the Certified Nurse Aide (CNA) Registry prior to employment start date for three out of ten new employees.
F655: The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident.
F656: The facility failed to implement individualized comprehensive care plans for two residents.
F661: The facility failed to ensure discharge/transfer documentation was complete for one resident discharged to a Residential Care Facility.
F761: The facility failed to store drugs and biologicals in accordance with accepted professional standards, affecting one resident.
A4017: The facility failed to comply with criminal background check requirements for new hires.
A4066: The facility failed to destroy outdated medications within 30 days as required.
A8008: The facility failed to fully inform residents or their representatives of services and charges prior to or at admission.
A8010: The facility failed to comply with advance directive requirements including annual notification to residents or representatives.
Report Facts
Facility census: 95
Number of sampled residents: 19
Number of new employees reviewed: 10
Number of residents with deficient baseline care plans: 1
Number of residents with deficient comprehensive care plans: 2
Inspection Report
Life Safety
Census: 95
Deficiencies: 3
Date: Apr 18, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire protection regulations, including exit discharge, smoking regulations, and electrical equipment safety.
Findings
The facility failed to maintain all-weather pathways on exit egresses, failed to maintain separation of cigarette butts and combustibles in smoking areas, and failed to restrict the use of power strips in resident rooms. These deficiencies potentially affected all residents and staff.
Deficiencies (3)
K271 Discharge from exits is not maintained free of obstructions and lacks a hard packed all-weather travel surface, affecting emergency egress for residents and staff.
K741 Smoking regulations are not met as the facility failed to maintain separation of cigarette butts and combustibles, with large amounts of cigarette butts observed in smoking area trash cans.
K920 Electrical equipment use is not restricted; power strips are used improperly in resident rooms, posing a safety risk.
Report Facts
Facility census: 95
Number of cigarette butts observed: 100
Inspection Report
Plan of Correction
Census: 21
Deficiencies: 3
Date: Nov 29, 2018
Visit Reason
The inspection was conducted to identify deficiencies related to emergency lighting, toilet room requirements, and ice machine contamination control at St Francois Manor.
Findings
The facility failed to ensure emergency lights operated for the required duration, maintain clean and well-maintained resident-use bathrooms, and provide an air gap for the ice machine drain pipe to prevent contamination.
Deficiencies (3)
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The emergency light between rooms #36 and #38 did not illuminate when tested and failed to operate for at least one and one-half hours.
19 CSR 30-87.020(41) Toilet Room Requirements. The resident-use bathroom was not kept clean or well maintained, with brown substances in the sink, stains, water leakage, and no out-of-order signage.
19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap. The facility failed to provide an air gap for the ice machine drain pipe, allowing potential contamination from backflow.
Report Facts
Facility census: 21
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 6
Date: Feb 1, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for the skilled nursing facility St. Francois Manor.
Findings
The facility was found deficient in multiple areas including call light system accessibility, development and implementation of comprehensive care plans, activity programs, psychotropic medication use, dental services, and infection control practices. Several residents were identified as being at risk due to these deficiencies.
Deficiencies (6)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to provide a call light system within reach of one resident's bed, limiting the resident's ability to alert staff for assistance.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans for two residents, including measurable objectives and preferences.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to develop an ongoing program supporting residents' choices of activities for three residents.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to adequately assess and evaluate psychotropic medication use to prevent unnecessary medications for one resident.
F790 Routine/Emergency Dental Services in SNFs: The facility failed to provide and assist with dental services for one resident, resulting in untreated oral health issues.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices, including cleaning of multi-use glucometers, putting residents at risk for infection.
Report Facts
Residents sampled: 18
Residents at risk: 89
Psychotropic medication review date: Jul 5, 2017
Plan of Correction completion date: Mar 16, 2018
Inspection Report
Life Safety
Census: 89
Deficiencies: 4
Date: Feb 1, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain exit pathways to a public way, operate the kitchen range hood, maintain the fire sprinkler system, and maintain smoking areas according to NFPA regulations. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (4)
K271 Discharge from Exits exit discharge is not maintained free of obstructions and lacks a hard packed all-weather travel surface. The exit pathway from the rear enclosed courtyard to a public way had a 15-foot long muddy ground before the rear parking lot.
K324 Cooking Facilities range hood failed to operate, affecting all residents and staff. The kitchen range hood was not turned on during cooking as required by NFPA 96.
K353 Sprinkler System maintenance and testing records were not maintained properly. Sprinkler heads in the kitchen and dining room had accumulation of dust and debris.
K741 Smoking Regulations smoking areas were not maintained according to NFPA regulations. The outside courtyard had a portable fire place with 30 cigarette butts and lacked metal self-closing cans and ashtrays.
Report Facts
Facility census: 89
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding exit pathway and sprinkler head cleaning | |
| Dietary Manager | Interviewed regarding range hood operation | |
| Administrator | Mentioned in plan of correction and smoking area maintenance |
Viewing
Loading inspection reports...
