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Complaint Investigation

St Andrew's At Francis Place

November 19, 2025 · Eureka, MO · 400 Summerville Blvd
Citations 1
CMS Rating 1/5
Beds 106
Provider ID 265195
Healthcare Facility
St Andrew's At Francis Place
Eureka, MO  ·  View full profile →
Inspection Summary

ST ANDREW'S AT FRANCIS PLACE in EUREKA, MO — inspection on November 19, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0561
Resident Rights Deficiencies
Actual Harm

During an interview on 11/18/25 at 9:33 A.M., LPN H said he/she is facility employed and had worked at the facility for three years. If a resident tells a CNA they don't want to get out of bed or get up to take a shower, he/she would expect the CNA to report that to him/her. He/She would tell the CNA to give the resident more time and reapproach the resident later or ask someone else to ask the resident. If the resident still does not want to get up, the resident would not have to get up. LPN H would not tell a CNA to get a resident up against the resident's will.

Residents have rights that should be respected.

He/She attended the transfer training in-service on 10/3/25. He/She reviewed the transfer training in-service signature page and said eleven of the twenty staff attending were agency staff. LPN H had not attended an in-service on resident's rights since 10/2/25.

During an interview on 11/19/25 at 8:20 A.M., the Director of Rehabilitation said prior to 10/2/25, the resident's transfer status was moderate assistance (50% of the transfer done by staff) of one staff.

The resident is able to make his/her own choices. If the resident does not want to get up out of bed, he/she should not have to get up.

During an interview on 11/19/25 at 8:56 A.M., the SSD said she completed the resident's BIMS on 11/7/25.

For the most part, the resident is able to make his/her needs known.

The resident would be able to say whether or not he/she wanted to get out of bed and/or take a shower.

Although the resident loves being in bed, staff should not make the resident do something he/she does not wish to do.

During an interview on 11/19/25 at 10:22 A.M. with the DON and Administrator, the DON said after she investigated the resident's skin tear, she was focused on the transfer itself rather than a resident's right issue.

That is why she had the Physical Therapist give a transfer training in-service on 10/3/25.

Not all nursing staff attended the in-service.

The day of the incident as well as throughout the week, she told staff in her conversations if a resident does not want to get up, don't get them up.

She did not tell all the staff, just the few she had conversations with.

The resident can make his/her needs known and staff should respect the resident's wishes.

The Administrator said on any given day, a good portion of their staff are agency staff.

She expected all staff, facility and agency, to follow the resident rights policy.

During a telephone interview on 11/19/25 at 12:14 P.M., the Medical Director said staff are not supposed to force residents to do something against their wishes. He would expect staff to follow their policy for resident's rights. He would have expected the facility to have in-serviced staff on resident's rights as well.

Observation on 11/19/25 at 1:05 P.M., showed the resident lay in bed. LPN B unwrapped the resident's dressing on the left lower leg showing two separate skin tears.

The left lower proximal leg was scabbed over, and the left lower distal leg remained open with a red floor (wound bed or the base of the wound). 26343682635144

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EUREKA, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ST ANDREW'S AT FRANCIS PLACE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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