Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Francois Manor during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and a history of stroke and brain dysfunction underwent multiple gradual dose reductions and discontinuations of Depakote and Seroquel ordered by a psych NP, but the resident’s representative was not notified of these medication changes. Facility policy required informed consent and notification of legal representatives for medication regimen changes, yet progress notes and the medical record contained no documentation of such notification or any request by the representative to forgo notifications. The DON reported she believed the guardian did not want to be contacted and therefore had not notified the representative about medication changes, while the Administrator stated she expected policy to be followed and notifications documented.
A resident with chronic low back pain, anxiety, depression, and schizophrenia had a care plan for pain that included medication administration, monitoring, and referral to pain management, but the facility did not follow through on key physician orders and referrals. Although imaging and a pain management consult were ordered and the resident requested stronger pain medication after reporting inadequate relief, the record showed no completed MRI, no documented pain management consult, and no documented alternative pain interventions after the guardian declined a Tramadol increase and requested pain management instead. The facility also lacked policies and procedures for implementing physician referrals and orders and for obtaining informed consent before changing medication regimens.
A resident with severe cognitive impairment and multiple diagnoses pulled out a urinary catheter, resulting in bleeding. There was no documentation that the physician or legal guardian was notified of this change in condition, as required by facility policy. The DON confirmed that staff are expected to notify both parties in such situations.
A resident with multiple complex diagnoses did not have required follow-up appointments with a urologist and nephrologist scheduled, and physician orders for urinary catheterization were not fully implemented or documented. Staff were unaware of certain orders, and monitoring of urine output was inconsistent, leading to a deficiency in care.
A resident with paranoid schizophrenia missed 18 doses of clonazepam due to a failure in the facility's medication ordering and tracking system. Despite staff attempts to manage the situation using emergency kit medications, the resident experienced increased paranoia and aggression, leading to an assault on another resident. The facility lacked a formal procedure for ordering and tracking medications, contributing to the oversight.
The facility failed to provide privacy curtains for two residents, resulting in a lack of privacy. Observations showed no curtains between beds, and residents expressed concerns about privacy and sleep disturbances. Staff interviews revealed confusion over responsibility for curtain installation, with the administrator expecting privacy protection.
The facility failed to provide a safe, clean, and homelike environment, with issues such as structural damage, cleanliness problems, and inadequate maintenance reporting. Residents reported insufficient cleaning, and staff interviews confirmed limited housekeeping duties and unresolved maintenance issues.
The facility failed to identify and address PTSD in the care plans of six residents, despite their diagnoses and documented behaviors. Trauma assessments were not conducted, and care plans lacked personalized triggers and interventions. Interviews with staff revealed a lack of awareness and expectation for addressing PTSD triggers.
A facility failed to ensure accurate medication administration and refills for two residents, leading to missed doses of essential medications. One resident with schizophrenia and PTSD did not receive several doses of Xifaxin and Seroquel XR, while another resident missed doses of medroxyprogesterone. Staff interviews revealed issues with medication refill requests and communication with the pharmacy, resulting in residents not receiving necessary medications.
Expired medications were found in the facility's storage room, including diphenhydramine, clindamycin, and nitroglycerin, despite monthly pharmacy checks. Interviews with staff revealed that the pharmacy had recently reviewed the medication rooms, but expired medications were still present, indicating a lapse in adherence to the facility's policy on medication storage.
Failure to Notify Resident Representative of Psychotropic Medication Changes
Penalty
Summary
Facility staff failed to notify a resident’s representative of multiple changes in the resident’s psychotropic medication regimen, contrary to facility policy requiring informed consent and notification of legal representatives for medication changes. The resident had a quarterly MDS indicating independence in cognitive skills for daily decision-making and activities of daily living, with diagnoses including stroke, non-traumatic brain dysfunction, and traumatic brain dysfunction. The POS and progress notes documented a diagnosis of schizoaffective disorder and a series of gradual dose reductions and discontinuations of Depakote and Seroquel over several months, ordered by a psychiatric NP. These orders included decreasing Depakote doses and ultimately discontinuing it, as well as discontinuing Seroquel. Progress notes recorded each medication change but contained no documentation that the resident’s representative was notified. The facility’s policy on Management of Psychotropic Medications and Unnecessary Medications, dated 04/2025, defined informed consent as providing the resident or legal representative with information about the medication regimen, including risks, benefits, and alternatives, and giving them the opportunity to accept or refuse treatment. Review of the medical record showed no documentation that the resident’s representative had requested not to be notified of medication changes. In an interview, the representative stated they only learned from the resident that medications had been discontinued and confirmed the facility had not contacted them about any dosage changes or discontinuations. The DON stated that facility policy is to contact all resident representatives for any change in condition, including medication changes, and that she is responsible for these notifications, but she had not contacted this resident’s guardian since May 2025 based on her understanding that the guardian did not want to be notified. The Administrator stated she would have expected the DON to follow facility policy and document notifications appropriately.
Failure to Follow Through on Pain Management Orders and Referrals
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with the resident’s comprehensive assessment, care plan, physician orders, and the resident’s goals and preferences. A cognitively intact resident with diagnoses including unspecified low back pain, anxiety, depression, and schizophrenia was care planned for back pain with interventions to administer pain medications as ordered, monitor pain characteristics and effectiveness of treatment, and refer to pain management as ordered. The resident’s MDS indicated frequent pain and use of scheduled, PRN medications and other interventions for pain. Progress notes documented that the resident reported chronic back pain and that existing pain medication was not effective. Physician orders and progress notes showed that an X‑ray, MRI of the lumbar and thoracic spine, and a pain management consult were ordered for low back pain, and later that the resident requested an increase in Tramadol after reporting higher doses received in the hospital. The primary care physician was notified, and a consent form was sent to the guardian for approval of the Tramadol increase, but the guardian refused and preferred that the resident attempt pain management first. The record contained no evidence that the ordered MRI was completed, no documentation of a pain management consult or referral follow‑through, and no documentation of attempts at alternative pain management as requested by the guardian. The facility also lacked policies and procedures for following through on physician referrals and orders, and for obtaining informed consent prior to medication increases or changes in the medication regimen.
Failure to Notify Physician and Guardian After Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician and legal guardian following a significant change in the resident's condition. Specifically, a resident with severe cognitive impairment, cerebral palsy, seizure disorder, anxiety disorder, and a mental disorder, who had a legal guardian, was found to have pulled out their urinary catheter with the balloon still inflated, resulting in blood on the bed mat. Documentation in the resident's progress notes did not indicate that the urinary catheter was re-inserted, nor was there any record that the physician or the guardian was notified of this change in condition. The facility's policy requires staff to observe, record, and report any change in a resident's condition to the attending physician and responsible party to ensure appropriate treatment. During an interview, the DON confirmed that staff are expected to contact both the physician and guardian in such situations. However, in this instance, there was no evidence that these notifications occurred after the resident's condition changed.
Failure to Follow Physician Orders for Catheterization and Specialist Follow-Up
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care for one resident with complex medical needs, including cerebral palsy, seizures, urine retention, obstructive and reflux uropathy, and acute kidney failure. Upon admission, there was no documentation that required follow-up appointments with a urologist and nephrologist were scheduled, despite clear instructions in the hospital discharge summary. Additionally, the facility did not have policies addressing intermittent catheterization or appointment scheduling, and the resident's medical record lacked evidence of assessment for urinary retention or the need for straight catheterization as ordered. Physician orders for urinary catheterization, including specific catheter size, frequency of change, and as-needed straight catheterization, were not fully implemented or documented. After the resident pulled out the urinary catheter, there was no documentation of reinsertion as ordered, and staff interviews revealed a lack of awareness regarding the straight catheterization order. Monitoring of urine output was inconsistent, with staff only documenting bowel movements and not tracking the number of wet briefs or assessing bladder distention as expected. The facility's failure to follow physician orders and ensure complete documentation led to the identified deficiency.
Medication Administration Failure
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for a resident diagnosed with paranoid schizophrenia, insomnia, and anxiety. The resident was prescribed clonazepam 0.5 mg to be administered four times daily. However, the resident missed 18 doses out of 28 opportunities over several days in November 2024. This lapse in medication administration was due to a failure in the facility's medication ordering and tracking system. The issue began when the resident's medication supply ran low, and staff members, including an LPN and a CMT, attempted to manage the situation by using medications from the emergency kit. Despite these efforts, the resident still missed multiple doses. The PNP had ordered the medication, but the pharmacy lost the request, leading to a delay in refilling the prescription. The facility lacked a formal procedure for ordering and tracking medications, which contributed to the oversight. Interviews with staff revealed a lack of communication and a system to ensure medication orders were placed and received in a timely manner. The DON was unaware of the medication shortage until it was too late, and the ADM expected the nursing staff to notify her when medications were low. The absence of a structured process for medication management resulted in the resident experiencing increased paranoia and aggression, culminating in an assault on another resident.
Lack of Privacy Curtains for Two Residents
Penalty
Summary
The facility failed to provide a privacy curtain to maintain privacy for two residents out of 18 sampled residents, with a facility census of 77. Observations on two separate days revealed that the residents did not have a privacy curtain between their beds. Resident #3 was observed lying in bed and folding clothes, while Resident #10 was seen sitting on their bed listening to music. Both residents expressed concerns about the lack of privacy, with Resident #3 mentioning the inability to change clothes privately due to being in a wheelchair and Resident #10 struggling to sleep because of the roommate's TV being visible at night. Interviews with staff members, including a housekeeper and the maintenance director, indicated a lack of clarity regarding responsibility for the installation and maintenance of privacy curtains. The housekeeper stated that housekeeping was not responsible for putting up privacy curtains, and the maintenance director mentioned that they would only address issues if something was broken. The facility administrator expressed an expectation that residents' privacy should be protected, yet the deficiency persisted, leaving the residents without adequate privacy measures.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of deficiencies in various rooms. In several rooms, there were structural issues such as holes in walls and ceilings, missing closet doors, and peeling cove base. Additionally, there were cleanliness issues, including brown films and dots on walls, gray/black fuzzy substances on bathroom vents, and sticky substances on floors. Residents reported that housekeeping only performed basic cleaning tasks and did not address these issues, which were supposed to be reported to maintenance by the staff. Interviews with residents and staff revealed that the cleaning and maintenance processes were inadequate. Housekeeping staff confirmed that their duties were limited to basic cleaning and that they reported environmental issues to their supervisor, who then informed maintenance. However, some issues, like the sticky stain on the floor, remained unresolved. The Director of Nursing and the Administrator acknowledged the expectation for the facility to be clean and in good repair, but the observations indicated a failure to meet these standards, affecting the overall environment for the residents.
Failure to Address PTSD in Resident Care Plans
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for six residents diagnosed with post-traumatic stress disorder (PTSD). These residents were not given trauma assessments, and their care plans did not address PTSD or include personalized triggers and interventions. This deficiency was observed in all six sampled residents, despite their documented diagnoses and behaviors related to PTSD. Resident #3's medical record showed multiple mental health diagnoses, including PTSD, but lacked documentation of a trauma assessment. The care plan did not address PTSD or personalized triggers. Similarly, Resident #17, with a history of sexual abuse and multiple mental health disorders, reported that staff had not discussed PTSD or triggers since admission. The care plan for Resident #17 also failed to address PTSD or personalized interventions. Other residents, including Resident #27, #33, #41, and #51, also had PTSD diagnoses without corresponding trauma assessments or care plans addressing their specific needs. Interviews with staff, including a CNA, RN, SSD, DON, and the Administrator, revealed a lack of awareness and expectation that PTSD triggers should be assessed and addressed in care plans, highlighting a systemic issue in the facility's approach to trauma-informed care.
Medication Administration and Refill Failures
Penalty
Summary
The facility failed to ensure accurate administration, documentation, disposal, and reconciliation of medications for two residents. Resident #3, who has multiple diagnoses including schizophrenia and PTSD, did not receive several doses of prescribed medications, including Xifaxin and Seroquel XR, over a period of days. The resident reported not receiving medications necessary for sleep and to prevent hallucinations. The facility's medication administration record (MAR) confirmed the missed doses. Resident #8, diagnosed with schizophrenia, also experienced missed doses of medroxyprogesterone over several days. Interviews with staff revealed that the facility had issues with medication refills and communication with the pharmacy. LPN I was unaware of the medication shortages, and CMT E explained the process for ordering medications, which included using a system link or faxing orders to the pharmacy. The pharmacy confirmed that medications were sent on the same day they were requested, but the facility failed to request refills in a timely manner or follow up on inquiries about refill timing. The Director of Nursing and the Administrator acknowledged that medications should be ordered before they run out. The facility's failure to manage medication orders and refills resulted in residents not receiving necessary medications, highlighting a breakdown in communication and procedure adherence within the facility.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted practices, which had the potential to affect all residents. During an observation of the medication storage room, it was found that there were four unopened vials of diphenhydramine with an expiration date of 03/2024, six tablets of clindamycin with an expiration date of 04/12/24, and one unopened bottle of nitroglycerin sublingual tablets with an expiration date of 04/20/24. These findings indicate that expired medications were present in the storage room, contrary to the facility's policy that requires outdated or deteriorated medications to be immediately removed from inventory and disposed of according to procedures. Interviews with staff revealed that the pharmacy visits the facility once a month to review the medication rooms and carts, with the most recent review occurring on 06/10/24. However, the presence of expired medications suggests that the monthly checks were insufficient or not thoroughly conducted. The Director of Nursing and the Administrator expressed that they expected the medication rooms and carts to be checked for expired medications at least monthly, ideally twice a month, indicating a gap between policy expectations and actual practice.
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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 Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Farmington Presbyterian Manor | 1.9 mi | ★★★★★ | 0 | 0 |
| Camelot Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 7 | 0 |
| Southbrook Nursing Center | 2.6 mi | ★★★★★ | 4 | 0 |
| Community Manor | 2.7 mi | ★★★★★ | 1 | 0 |
| Country Meadows | 8.6 mi | ★★★★★ | 1 | 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.