St Francois Manor: Catheter Care Failure Cited - MO
That finding sits at the center of a complaint inspection completed in November 2025 at the Farmington nursing home. The resident had a physician's order for straight catheterization as needed. When the catheter came out, staff did not reinsert it. They did not monitor urine output. According to inspection records, what staff documented instead was bowel movements.
The gap between what the physician ordered and what staff actually did is what inspectors cited under federal tag F0684, which covers the standard of care residents receive. The violation was classified as having minimal harm or potential for actual harm, and inspectors noted that few residents were affected.
But the Director of Nursing, interviewed on September 29 at 2:33 in the afternoon, said she did not know why the catheter had not been reinserted. That answer, recorded in the inspection report, is the kind of answer that tends to linger. A resident needed a catheter. It came out. The person responsible for nursing oversight at the facility could not explain why no one acted on it.
She said she would expect urine output to be monitored for a resident with an order for straight catheterization as needed. She said she would expect staff to follow physician orders. What she expected and what happened were not the same thing.
The administrator, interviewed four days earlier on September 25 at 4:35 in the afternoon, said much the same. She would expect staff to follow physician orders. She would expect orders to be complete. She would expect follow-up appointments to be scheduled.
Those are reasonable expectations. They are also, in this case, a description of things that did not happen.
A physician's order for straight catheterization as needed exists for a reason. A catheter that is pulled out and not reinserted means urine is not draining the way the physician determined it needed to drain. Monitoring output is how staff know whether a problem is developing. When the only documentation is bowel movements, there is no record of what the urinary tract was doing, no baseline, no way to catch a change.
The inspection was triggered by a complaint, filed under complaint number 2616588. Someone contacted regulators. The inspection that followed confirmed what the complaint described.
St Francois Manor is a nursing facility in Farmington, in St. Francois County in southeastern Missouri. The inspection covered this single complaint, and the record available runs three pages. This was not a sweeping survey of the entire facility. It was a narrow look at one resident's care, and what that narrow look found was a physician's order that went unfollowed, a catheter that stayed out, and documentation that recorded the wrong thing.
The administrator and the Director of Nursing both described, when asked, what proper care would look like. Neither offered an explanation for why it had not been provided. The DON said she did not know. That is the word used in the inspection report: did not know.
A resident with a catheter order is a resident whose body requires that kind of intervention. The physician made that determination. When the catheter came out, the clock started on how long the resident went without it. The inspection report does not say how long that was. It says the catheter was not reinserted. It says urine output was not monitored. It says staff documented bowel movements.
What the record does not contain is an explanation. The two people at the top of the facility's clinical and administrative structure were asked directly, and neither could account for what happened to that resident's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Francois Manor from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
ST FRANCOIS MANOR in FARMINGTON, MO was cited for violations during a health inspection on November 17, 2025.
That finding sits at the center of a complaint inspection completed in November 2025 at the Farmington nursing home.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.