Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) D, an agency CNA, respected Resident #24's right to remain in bed. On 10/2/25, the CNA transferred the resident out of bed for a shower after the resident told the CNA he/she did not want to get out of bed. The resident said he/she was upset about being made to get up, the transfer was rough and felt like a tussle. During the transfer, the resident sustained a large skin tear, approximately ten centimeters (cm) long, to the left lower leg. The resident was sent to the hospital where five sutures were required to close the skin tear. The facility investigated the incident and in-serviced some nursing staff on transfer training. …
F561 citations in Missouri
Self-determination · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F561 more often than its own record predicts
2.42 times the share F561 takes of citations nationally.
Of every deficiency written in Missouri in 2025, this is the portion that was F561.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F561 findings written in Missouri, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Residents #9, #80, #38, and #85). The facility census was 87. Review showed the facility did not have a policy pertaining to the frequency and provision of showers per residents' preferences. 1. Review of Resident #9's face sheet (gives basic profile information), showed the following:-admitted to the facility on [DATE];-Diagnoses included anxiety disorder, yeast infection of genital areas (fungal infection), urinary tract infection (UTI), dementia, reduced mobility, depression, Rheumatoid arthritis (long term disease where body's immune system mistakenly attacks the… …
Based on observation, interview and record review, the facility failed to ensure the resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident by not providing coffee in the morning prior to the service of breakfast for one resident (Resident #86) and not providing residents access to the dining room outside of meal service hours. This had the potential to affect all residents who would choose to utilize the dining room during times outside of meal service and/or drink coffee at times dietary staff are not available. The census was 130. 1. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.67% | 1.27× |
| 2024 | 0.62% | 1.50× |
| 2025 | 0.93% | 2.42× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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