Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Andrew's At Francis Place during CMS and state inspections, most recent first.
A CNA failed to honor a resident's right to refuse getting out of bed for a shower, proceeding with a transfer despite the resident's objections. The resident, who was able to communicate their wishes, sustained a significant skin tear during the transfer, requiring hospital treatment. The incident revealed that staff did not consistently respect or understand resident rights, and the facility's investigation focused on transfer technique rather than the violation of self-determination.
A resident did not receive appropriate care or services to maintain or improve range of motion (ROM) and mobility, and the facility did not ensure interventions were in place to prevent decline unless medically unavoidable.
The facility failed to accommodate resident preferences and needs, leading to deficiencies in care. Two residents faced issues with room arrangements that hindered access to personal belongings and wheelchair maneuverability. Additionally, the facility removed siderails from beds without providing alternatives or conducting proper assessments, affecting four residents who relied on them for mobility and repositioning. The facility's policies on adaptive devices were not followed, and there was confusion among staff about assessment responsibilities.
The facility failed to maintain consistent and updated code status documentation for four residents, leading to discrepancies between their wishes and recorded medical directives. The policy requires residents to complete a therapeutic support level/resuscitation plan upon admission, but inconsistencies were found in the EMR and nurse's report sheets. Interviews with staff revealed lapses in verifying and updating code status information, contributing to the deficiency.
The facility failed to maintain cleanliness and food safety standards in the kitchen, with equipment like the stove and fryer found with heavy stains and old grease. Expired milk was also not discarded, as observed over several days. The Dietary and Kitchen Managers acknowledged the lapses in cleaning and food disposal protocols, affecting the facility's 73 residents.
The facility failed to track the required 12 hours of annual education for CNAs and CMTs, as documentation did not include the length of time for completed in-services. The Administrator acknowledged the lack of tracking and inability to confirm if staff received the mandated education.
The facility failed to follow up on TPL forms for a deceased resident, resulting in a deficiency. A resident's account remained open with a balance of $481.39 beyond the 30-day period after death. The Corporate Business Office Manager admitted to not following up with the TPL unit in a timely manner, contrary to the Administrator's expectations.
The facility failed to update care plans for two residents, one with a fall risk and another with a hospice diagnosis. A resident with impaired cognition and multiple diagnoses experienced an unwitnessed fall, but their care plan did not reflect fall risk or interventions. Another resident receiving hospice care had no updates in their care plan to reflect hospice status, despite a physician's order. Interviews confirmed that care plans should be updated following changes in condition.
The facility did not follow physician orders for two residents. One resident, with multiple health issues, had orders for daily and weekly weights, but only one weight was recorded. Another resident, on hospice care, lacked a documented physician's order for hospice, despite it being noted in their care plan. The DON confirmed the need for a physician's order for hospice care.
The facility failed to implement a 14-day stop date for PRN psychotropic medications for two residents with severe cognitive impairments. One resident had an order for Lorazepam without a stop date, while another had an order for Quetiapine for agitation, also lacking a stop date. Staff interviews confirmed the expectation for a 14-day stop date on such medications.
The facility failed to document treatments for a resident's stage four pressure ulcer consistently, with multiple instances of blank entries in the TAR. Additionally, another resident receiving hospice care lacked the required certification of terminal illness form in their records. These deficiencies indicate lapses in documentation practices, which are essential for ensuring proper care and oversight.
The facility failed to follow infection control standards by not ensuring staff wore appropriate PPE for two residents and did not post necessary signage for another resident requiring Enhanced Barrier Precautions (EBP). Staff did not wear gowns while repositioning a resident with an indwelling catheter, and the catheter drain was observed touching the floor without being sanitized. Another resident with a G-tube on EBP was assisted without PPE due to flipped signage. Additionally, a resident with a suprapubic catheter and MDRO lacked visible signage and accessible PPE supplies.
The facility failed to ensure residents received treatment and care according to professional standards, with significant documentation gaps for ordered treatments. A resident with a g-tube and another with a suprapubic catheter did not receive documented care, and similar issues were noted for other residents. Interviews confirmed expectations for staff to follow orders and document treatments, but consistent failures were observed, particularly with evening and agency staff.
A resident, who is cognitively intact and has multiple health conditions, experienced a deficiency in dignity and respect when their preference for female caregivers was not honored. Despite expressing this preference during a care plan meeting, a male CNA assisted the resident with toileting and bedtime routines, leading to distress. The CNA did not respect the resident's wishes regarding personal care routines, resulting in a deficiency finding.
The facility failed to follow its fall policy by not conducting necessary assessments and neurological checks for three residents after falls. A resident returned from the hospital without documented neuro-checks, another had a head injury without consistent documentation, and a third had multiple falls without completed assessments. This led to a deficiency in care.
An LPN at a facility was found to have misappropriated controlled substances, including oxycodone and Ativan, from multiple residents. The facility's policies on controlled substance management and reporting were not effectively enforced, allowing the LPN to remove medications unauthorizedly over several days. The LPN was observed on video taking narcotics and discrepancies were noted in narcotic sign-out sheets.
The facility failed to report the misappropriation of controlled substances by an LPN within the required timeframe, affecting multiple residents. The LPN was found to have diverted medications such as oxycodone and Ativan, with discrepancies noted in narcotic sign-out sheets and video evidence showing the LPN placing narcotics in their pocket. This delay in reporting compromised resident safety.
A facility failed to suspend an LPN during an investigation into alleged misappropriation of controlled substances, allowing the LPN to continue working and misappropriate medications from multiple residents. The facility did not follow its policy of suspending staff pending investigation, resulting in continued medication discrepancies. Additionally, the facility failed to conduct thorough investigations into other incidents, such as missing resident property, and did not report findings to the DHSS within the required timeframe.
A resident with severe cognitive impairment fell while using a walker, and the facility failed to follow a stat x-ray order for the resident's right shoulder and humerus. The incident was not documented, and no investigation was conducted. The RN did not document the fall or follow up on the x-ray order, and the resident was monitored overnight without complaints of pain. The next day, severe pain and swelling were noted, and the x-ray revealed a complex fracture, leading to hospital treatment.
A resident with moderate cognitive impairment and multiple sclerosis fell out of bed during perineal care due to a CNA's lack of awareness of the two-person assistance requirement. The facility's system for accessing care plans via iPhone was not effectively utilized by all staff, resulting in inadequate supervision and care.
Resident's Right to Refuse Care Not Honored, Resulting in Injury
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA), who was an agency staff member, failed to respect a resident's right to self-determination by transferring the resident out of bed for a shower despite the resident's explicit refusal. The resident, who had diagnoses including high blood pressure, arthritis, weakness, and chronic pain, was assessed as having moderate cognitive impairment but was able to make their needs known and communicate effectively. The resident verbally communicated to the CNA that they did not want to get out of bed, but the CNA proceeded with the transfer after being told by a nurse that the resident would be fine once up. During the transfer, the resident resisted, and the CNA used a bear hug technique to move the resident from the bed to the wheelchair. As a result of the transfer, the resident sustained a significant skin tear, approximately ten centimeters long, to the left lower leg, which required hospital treatment and sutures. The incident was witnessed by other staff who noted the CNA appeared verbally agitated, and the resident later described the transfer as rough and feeling like a tussle. The resident expressed being upset about being made to get up and reported pain and ongoing discomfort from the injury. The care plan and medical records confirmed the resident's ability to make choices and the expectation that staff would respect those choices, including the right to refuse care. The facility's investigation into the incident focused primarily on the mechanics of the transfer rather than the violation of the resident's rights. Interviews with staff revealed inconsistent understanding and application of resident rights, with some staff indicating they would follow a nurse's directive even if it contradicted a resident's expressed wishes. The facility's policies and resident handbook emphasized the importance of resident choice and self-determination, but these were not followed in this instance, leading to the resident's rights being disregarded during the event.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve ROM and mobility were not implemented as required.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents, leading to deficiencies in their care. Two residents experienced issues with room arrangements that hindered their ability to access personal belongings and maneuver their wheelchairs. Despite expressing their preferences for bed placement against the wall, the facility staff rearranged the rooms, citing state regulations, which resulted in one resident being unable to reach their nightstand and another struggling to move around due to limited space. The facility did not address these concerns adequately, as staff members were either unaware of the issues or did not take action to resolve them. Additionally, the facility removed all siderails from residents' beds without providing alternative options or conducting proper assessments. Four residents who relied on siderails for mobility and repositioning were affected by this decision. These residents expressed that the siderails helped them feel safer and more independent, yet the facility removed them, citing regulations and corporate decisions. The lack of siderail assessments and the absence of alternative solutions left these residents without necessary support for their mobility needs. The facility's policies and procedures regarding adaptive and assistive devices were not followed, as evidenced by the lack of evaluations and consent for the removal of siderails. The therapy department was not involved in assessing the need for adaptive equipment, and there was confusion among staff about who was responsible for conducting these assessments. The facility's administrator acknowledged the removal of siderails and the ongoing evaluation of their usage, but the residents' care plans were not updated to reflect their needs without siderails, leading to deficiencies in their care.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to maintain consistent and updated code status documentation for four out of 18 sampled residents, leading to discrepancies between the residents' wishes and the recorded medical directives. The facility's policy requires that upon admission, residents or their representatives complete a therapeutic support level/resuscitation plan to ensure timely intervention in emergencies. However, the survey revealed inconsistencies in the documentation of code statuses in the electronic medical records (EMR) and the nurse's report sheets. For Resident #18, there was a conflict between the scanned DNR form and the TSL/Resuscitation Plan, which indicated a full code status. Similarly, Resident #14's records showed a discrepancy between the TSL form indicating full code and the advanced directive tab showing a DNR. Resident #17 and Resident #62 had outdated TSL/resuscitation plans, which had not been updated as required by the facility's policy. These inconsistencies suggest a failure in the process of verifying and updating code status information during admission and annually thereafter. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, highlighted that the responsibility for obtaining and updating code status information lies with the nurses and clinical support staff. The DON acknowledged the need for immediate updates to Resident #18's code status, while the Administrator emphasized the expectation for staff to update code statuses annually and upon any changes requested by residents or their representatives. These lapses in documentation and adherence to policy contributed to the deficiency identified by the surveyors.
Deficiencies in Kitchen Cleanliness and Food Safety
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in the kitchen, as observed over a period of five out of six days. The kitchen equipment, including the stove, steamer, flat grill, and deep fryer, were found with heavy caked-on stains and old grease, indicating a lack of regular cleaning. The cleaning schedules reviewed showed inconsistencies, with some equipment not listed or not initialed as cleaned on certain days. This lack of adherence to cleaning protocols was confirmed during interviews with the Dietary Manager and Kitchen Manager, who acknowledged the expectation for daily general cleaning and a rotational cleaning schedule for certain items. Additionally, the facility failed to discard expired thickened milk, which was observed in the cooler on multiple occasions. The expired milk cartons were not properly labeled or removed, as confirmed by the Dietary Manager, who stated that all items should be labeled, dated, and expired items discarded. The Kitchen Manager also noted that everyone is responsible for ensuring proper labeling and disposal of expired food. These deficiencies in food safety and cleanliness had the potential to affect all residents consuming food from the facility kitchen, given the facility's census of 73 residents.
Deficiency in Tracking CNA and CMT Education Hours
Penalty
Summary
The facility failed to ensure a system was in place to track the required 12 hours of annual education for Certified Nurse Aides (CNAs) and Certified Medication Technicians (CMTs). The review of employee files for six CNAs and four CMTs revealed that while in-services were completed, the documentation did not include the length of time the training was provided. This lack of documentation made it impossible to verify if the staff received the mandated 12 hours of education. During an interview, the Administrator acknowledged that the facility did not track the time for the in-services and could not confirm whether the CNAs or CMTs had received the required education. The Administrator expressed an expectation that staff should have the required education and that the hours should be tracked, indicating a gap between the facility's expectations and its practices.
Failure to Follow Up on TPL Forms for Deceased Resident
Penalty
Summary
The facility failed to ensure timely follow-up on third party liability (TPL) forms for the final accounting of a resident who expired, resulting in a deficiency. This issue affected one of five residents who had money in their resident trust account at the time of death. Specifically, the resident had a balance of $481.39 in their account, and although the TPL form was completed, the account remained open with the same balance beyond the 30-day period. The Corporate Business Office Manager acknowledged the delay in following up with the TPL unit to close the account and admitted that she should have acted sooner. The Administrator expected the TPL form to be submitted within 30 days and follow-up to ensure a zero balance in the resident's account, which was not met in this case.
Failure to Update Care Plans for Fall Risk and Hospice Status
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in addressing their current health needs. Resident #26, who has moderately impaired cognition and multiple diagnoses including cancer and paraplegia, experienced an unwitnessed fall in their room. Despite the facility's policy requiring immediate updates to care plans following a fall, the care plan for Resident #26 did not reflect their fall risk or include interventions to prevent future falls. This oversight indicates a failure to adhere to the facility's Fall Risk Reduction policy, which mandates updating the care plan and implementing interventions after a fall. Resident #56, who was admitted to the facility with moderate cognitive impairment and a prognosis indicating a life expectancy of less than six months, was receiving hospice care. However, the care plan was not updated to reflect the resident's hospice status, goals, or interventions, despite a physician's order for a hospice consult. Interviews with the MDS Coordinator and the Administrator confirmed that care plans should be updated following changes in a resident's condition, such as a fall or a new hospice diagnosis, to ensure CNAs have accurate information to provide appropriate care.
Failure to Follow Physician Orders for Weights and Hospice Care
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following physician orders for two residents. For one resident, the facility did not record daily and weekly weights as ordered by the physician. The resident, who had diagnoses including anemia, malnutrition, hypertension, heart disease, and heart failure, had a physician order for daily weights every Tuesday and weekly weights, but only one weight was recorded. This oversight was acknowledged by the Administrator and Director of Nursing during an interview. For another resident, the facility did not obtain a physician's order for hospice care, despite the resident being on hospice care as indicated in their care plan. The resident had severe cognitive impairment and multiple diagnoses, including anemia, heart failure, and Alzheimer's disease. The care plan noted the resident was receiving palliative care directed by a hospice interdisciplinary team, but the medical records lacked a documented physician's order for hospice care. The Director of Nursing confirmed that there should have been a physician's order for hospice care.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to implement a 14-day stop date for the PRN use of psychotropic medications or provide a rationale for the continued use of the medication for two residents. Resident #18, who was readmitted with severe cognitive impairment and diagnoses including Alzheimer's disease, stroke, anxiety, and depression, had a physician order for Lorazepam Intensol Oral Concentrate without a documented stop date. The resident's care plan included the use of antidepressant and anti-anxiety medications, with interventions to monitor and document side effects and effectiveness every shift. Resident #15, admitted with severe cognitive impairment and diagnoses of dementia and depression, had a physician order for Quetiapine Fumarate Tablet for agitation, also without a documented stop date. The resident's care plan focused on meeting emotional, intellectual, physical, and social needs related to cognitive deficits, but did not mention the use of psychotropic medication. Interviews with facility staff, including an LPN and the Administrator and DON, confirmed that all PRN psychotropic medications should have a 14-day stop date, and a new order should be obtained if needed.
Incomplete Documentation of Treatments and Hospice Certification
Penalty
Summary
The facility failed to ensure complete and accurate documentation of resident records, specifically for two residents. For one resident, the facility did not document the treatments for a stage four pressure ulcer consistently. The Treatment Administration Record (TAR) showed multiple instances where documentation was left blank, indicating that treatments may not have been completed as ordered. There was no documentation of treatment refusals or notifications to the physician, which is required when treatments are not administered as prescribed. Interviews with staff revealed that treatments should be documented after completion, and if not documented, it is assumed they were not done. Another resident receiving hospice services did not have the required certification of terminal illness form in their medical records or hospice binder. The resident had been admitted to hospice care recently, but the necessary documentation was not available in the facility at the time of the survey. The facility administrator acknowledged the absence of the form and mentioned that the hospice provider was in the process of sending it over. These deficiencies highlight lapses in the facility's documentation practices, which are crucial for ensuring that residents receive appropriate care and that their medical records are maintained according to professional standards. The lack of documentation for treatments and hospice certification could lead to inadequate care and oversight of residents' medical needs.
Infection Control Deficiencies in PPE Use and Signage
Penalty
Summary
The facility failed to adhere to infection control standards by not ensuring staff wore appropriate Personal Protective Equipment (PPE) for two residents and did not post necessary signage for another resident requiring Enhanced Barrier Precautions (EBP). Specifically, staff did not wear gowns while repositioning a resident with an indwelling catheter and stage four pressure ulcers, and the catheter drain was observed touching the floor without being sanitized before being placed back in the holder. This oversight was confirmed through interviews with various staff members who acknowledged the need for sanitation if the catheter drain touched the floor. Another incident involved a resident with a G-tube who was on EBP, yet staff failed to wear gloves or gowns while assisting the resident in the bathroom. The EBP signage on the resident's door was not visible, leading to staff being unaware of the need for PPE. Interviews with the staff involved revealed a lack of awareness about the resident's EBP status, which was attributed to the signage being flipped over and not visible. Additionally, a resident with a suprapubic urinary catheter and MDRO was on EBP, but there was no signage on the door, and PPE supplies were not readily available near the resident's room. Interviews with staff indicated that they relied on door signage and verbal reports to identify residents on EBP, but the absence of visible signage and accessible PPE supplies contributed to the failure to follow proper infection control protocols.
Failure to Document and Administer Ordered Treatments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for residents with specific medical needs. Resident #3, who has a gastronomy tube and is at risk for pressure ulcers, did not receive documented skin observations, Calmoseptine applications, g-tube site care, and wound care as ordered. Observations revealed the g-tube site was not properly dressed, and interviews indicated that the dressing was often missing, suggesting a lack of adherence to care protocols. Resident #1, who had a suprapubic catheter and was at risk for pressure ulcers, also did not receive documented treatments as ordered, including zinc oxide applications, catheter flushes, and wound care. The resident was hospitalized and later expired, but during their stay, there were significant gaps in the documentation of care provided. This lack of documentation implies that the treatments were not administered as required. Additional residents, including Residents #2, #4, #5, and #6, also experienced similar issues with missing documentation for ordered skin treatments and observations. Interviews with the Director of Nursing and the Administrator confirmed that staff are expected to follow orders and document treatments, and any failure to do so should be reported. However, the report highlights consistent failures in documentation and treatment administration across multiple shifts, particularly the evening and agency staff.
Failure to Honor Resident's Caregiver Preferences
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, leading to a deficiency in treating the resident with respect and dignity. The resident, who is cognitively intact and has multiple diagnoses including heart failure and renal failure, expressed a clear preference for female staff during a care plan meeting. Despite this, a male CNA assisted the resident with toileting and bedtime routines, which the resident found distressing. The resident reported that the male CNA was rough and did not respect their wishes regarding personal care routines, such as wearing panties to bed and the placement of their wheelchair and bedside table. The incident occurred when the resident needed assistance to use the restroom and go to bed. The male CNA, identified as CNA A, did not follow the resident's instructions and became frustrated, handling the resident roughly and disregarding their preferences for personal items' placement. The resident had previously communicated their caregiver preferences, which included a list of acceptable staff members, to the staffing coordinator. However, this preference was not honored, leading to the incident and subsequent deficiency finding.
Failure to Follow Fall Policy and Conduct Neurological Checks
Penalty
Summary
The facility failed to adhere to its fall policy by not conducting necessary assessments and neurological checks following falls for three residents. Resident #2 experienced an unwitnessed fall and was sent to the hospital with a head laceration. Upon return, the facility did not document the required neurological checks every four hours for 72 hours, as per policy. Additionally, there was no completed neuro-check form to show the results of assessments, including motor function and pupil response. Resident #9 had an unwitnessed fall resulting in a head injury, but the facility did not complete a fall assessment or document all required neurological checks. The resident was found with a bump on the forehead and skin tears, yet the neuro-checks were not consistently documented, and no neuro-check form was completed to show the results of assessments. Resident #8 had multiple unwitnessed falls, but the facility failed to complete fall assessments for each incident. After a fall on 10/6/24, there were no documented neuro-checks or completed neuro-check forms to show the results of assessments. The facility's failure to follow its fall policy and document necessary assessments and interventions contributed to the deficiency.
Misappropriation of Controlled Substances by LPN
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of controlled substances for 11 residents. This deficiency was identified through interviews and record reviews, revealing that controlled substances were unauthorizedly removed by an LPN. The facility's policy on Resident Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property was not effectively implemented, as evidenced by the unauthorized removal of medications such as oxycodone, Norco, Percocet, and Ativan. The facility's investigation showed that the LPN was observed on video taking narcotics and placing them in their pocket, and discrepancies were noted in narcotic sign-out sheets and Medication Administration Records. The investigation revealed that the LPN had signed out narcotics multiple times without proper documentation and had signed out medication for a resident without an active order. The facility's Controlled Substance policy, which requires accurate accountability and documentation of controlled substances, was not adhered to, leading to the unauthorized removal of medications. The LPN was identified as the individual responsible for the discrepancies, and it was discovered that their nursing license had been previously placed on probation for a similar offense. The deficiency was further compounded by the facility's failure to recognize and investigate the involvement of an additional resident in the misappropriation. The facility's policies on discrepancies, loss, and diversion of medications, as well as controlled substance audits, were not effectively enforced, allowing the LPN to continue unauthorized activities over several days. The facility's lack of timely reporting and investigation of the incidents contributed to the deficiency, resulting in the unauthorized removal of controlled substances from the residents.
Failure to Report Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to report alleged violations involving the misappropriation of controlled substances within the required 24-hour timeframe to the Department of Health and Senior Services (DHSS), law enforcement, and the Board of Nursing. This failure involved two nurses, LPN C and LPN D, and affected 11 residents. The facility's policy mandates immediate investigation and reporting of any suspected abuse, neglect, or misappropriation of resident property, but these procedures were not followed in this instance. The investigation revealed that LPN B was involved in the unauthorized removal of controlled substances, including oxycodone, Norco, Percocet, and Ativan, from the facility. The facility's records showed discrepancies in narcotic sign-out sheets and Medication Administration Records, with LPN B's signature appearing multiple times for medications not documented as administered. Video evidence suggested that LPN B was placing narcotics in their pocket, and LPN B admitted to taking medication not prescribed to them. Despite these findings, the facility delayed reporting the incident to the appropriate authorities. The affected residents, including those with no active orders for pain medication, were subjected to potential harm due to the diversion of their prescribed medications. Resident #11, for example, was cognitively intact and had a history of hip fracture and pain but was not on a scheduled pain medication regimen. The facility's failure to promptly report and address the diversion of medications compromised the safety and well-being of the residents involved.
Failure to Suspend LPN During Investigation Leads to Continued Misappropriation
Penalty
Summary
The facility failed to prevent further misappropriation and diversion of controlled substances by not adhering to its policy of suspending staff during an investigation. LPN C and LPN D reported alleged violations by LPN B, who was accused of misappropriating and diverting medications. Despite these allegations, LPN B was allowed to continue working for three days, during which time the misappropriation continued, affecting nine residents. The facility's policy clearly states that employees alleged to have committed abuse or neglect should be suspended pending investigation, which was not followed in this case. The report highlights specific instances of medication misappropriation involving several residents. For example, Resident #11, who was cognitively intact and had a history of hip fracture and pain, had Norco signed out by LPN B without documentation of administration. Similarly, Resident #15, with severe cognitive impairment and chronic pain, had Percocet signed out more frequently than prescribed, and there was no documentation of administration for MS Contin. These discrepancies indicate a failure to maintain accurate medication records and ensure proper administration. Additionally, the facility failed to conduct thorough investigations into other incidents, such as a resident's missing device and another resident's missing wallet and money. The facility did not submit a completed investigation to the Department of Health and Senior Services within the required timeframe. The lack of comprehensive investigations and timely reporting further demonstrates the facility's failure to adhere to its policies and regulatory requirements, contributing to the overall deficiency.
Failure to Follow Stat X-ray Order and Document Fall Incident
Penalty
Summary
The facility failed to follow a Nurse Practitioner's (NP) order for a stat x-ray of a resident's right shoulder and humerus after the resident experienced a fall while using a rollator walker. The incident was not documented in the resident's medical record, and no investigation into the fall was conducted. The resident, who had severe cognitive impairment and a history of falls, was observed on video footage falling to the floor, after which a dietary aide sought help. A Registered Nurse (RN) assessed the resident and moved them to a wheelchair without documenting the incident or following up on the stat x-ray order. The RN contacted the NP, who ordered a stat x-ray, but the RN was unable to reach the x-ray company and did not document the order or inform the oncoming Charge Nurse. The RN claimed to have been unfamiliar with the facility's electronic health record system, which contributed to the lack of documentation. The resident was monitored overnight without complaints of pain, likely due to their dementia, and the stat x-ray order was not communicated to the next shift. The following day, a Licensed Practical Nurse (LPN) noted the resident's severe pain and swelling in the right arm and contacted the NP, who reiterated the stat x-ray order. The x-ray revealed a complex fracture, and the resident was sent to the hospital for treatment. The Director of Nursing (DON) and Nurse Manager were unaware of the fall and the x-ray order until informed by the LPN. The NP stated that if informed of the inability to contact the x-ray company, they would have ordered the resident to be sent to the hospital immediately.
Failure to Provide Two-Person Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and care as per the care plan for a resident with moderate cognitive impairment and multiple sclerosis, resulting in the resident falling out of bed. The resident's care plan required two staff members to assist with bed mobility and repositioning. However, during perineal care, a CNA attempted to provide care alone, leading to the resident rolling out of bed and sustaining minor abrasions. The CNA was unaware of the two-person assistance requirement, as this information was not readily accessible in the resident's medical record or known to the CNA at the time. Interviews revealed that the facility had a system in place for CNAs to access resident care information via a designated iPhone, but not all staff were familiar with its use. The Director of Nursing and the Administrator acknowledged that CNAs were expected to check the facility's iPhone for care instructions before providing care. However, it was discovered that some CNAs were not aware of this resource or how to use it, leading to a lack of proper communication and understanding of the resident's care needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eureka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marymount Manor | 1.8 mi | ★★★★★ | 1 | 0 |
| Aegis Health And Rehabilitation | 4.1 mi | ★★★★★ | 1 | 0 |
| Ellisville Rehabilitation And Nursing | 5.6 mi | ★★★★★ | 22 | 3 |
| Pacific Care Center | 6 mi | ★★★★★ | 21 | 0 |
| Lutheran Senior Services At Meramec Bluffs | 7.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.