St. Andrew's at Francis Place: Resident Rights Violated - MO
The November 2025 complaint inspection at St. Andrew's at Francis Place found that staff had transferred the resident against their expressed wishes, causing physical injury. Federal inspectors rated the violation at the level of actual harm.
The resident is cognitively capable of making their own wishes known. The Social Services Director, interviewed on the final day of the inspection, said the resident had scored well enough on a standard cognitive assessment that they could clearly communicate whether they wanted to get out of bed or take a shower. "Although the resident loves being in bed," the Social Services Director said, "staff should not make the resident do something he/she does not wish to do."
Nobody disputed that. Every staff member and administrator interviewed said the same thing: residents have rights, and a resident who says no should not be forced. The Director of Rehabilitation noted that before the incident, the resident's transfer status required moderate assistance from one staff member, meaning the move took real physical effort, not just a guiding hand. The Medical Director said he would have expected the facility to in-service staff on resident rights after an incident like this.
The problem was what actually happened after the resident was hurt.
When the Director of Nursing investigated the skin tear on the resident's leg, she said she focused on the mechanics of the transfer rather than the rights violation underneath it. That framing shaped the facility's response. On October 3, a Physical Therapist led a transfer training in-service. Eleven of the twenty staff who attended that session were agency workers. The in-service covered how to move a resident. It did not address whether a resident could refuse to be moved at all.
The Director of Nursing acknowledged that after the incident and throughout that week, she told staff in her conversations that if a resident does not want to get up, don't get them up. She did not address all staff. She addressed the few she happened to speak with.
CMT G, interviewed during the inspection, said their own practice was to check with the resident first, and if the resident refused, to notify the charge nurse rather than proceed. CMT G had attended the October 3 transfer training but had not received any in-service on resident rights since October 2, the day before the transfer session. LPN H, a three-year facility employee, said the same: residents have rights that should be respected, and no CNA should be told to get a resident up against their will. LPN H also had not attended a resident rights in-service since October 2.
The Administrator told inspectors she expected all staff, facility and agency alike, to follow the resident rights policy. She acknowledged that on any given day, a good portion of the staff working in the building are agency workers.
When inspectors observed the resident on the afternoon of November 19, they were lying in bed. A nurse unwrapped the dressing on the resident's left lower leg and revealed two separate skin tears. The proximal wound had scabbed over. The distal wound had not. Its wound bed was red and open.
The injury happened because someone moved a resident who did not want to be moved. The facility's response was to teach staff how to perform transfers more safely, not to confront the question of whether a resident's refusal had to be honored. A nurse told a small number of colleagues the right answer in passing conversations. Agency staff, who made up more than half of the transfer training's attendees, received no formal instruction on resident rights at all.
The resident was still in bed when inspectors left. The wound on their leg had not closed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Andrew's At Francis Place from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ST ANDREW'S AT FRANCIS PLACE in EUREKA, MO was cited for violations during a health inspection on November 19, 2025.
The November 2025 complaint inspection at St.
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.