Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary physical restraint for three of 42 sampled residents (Residents (R)136, R70, and R31) along with implementing behavioral health interventions to prevent injury and excessive force and failed to investigate emergency events that led to an injury for R136. The census was 178. Immediate Jeopardy related to this failure was identified on 11/15/23 and was determined to first exist since 07/11/23 when the facility failed to ensure R136 wasn't physically restrained while sustaining an injury. On 11/15/23 at 5:31 PM, the facility's Administrator was notified of the Immediate Jeopardy. The facility Administrator was notified the Immediate Jeopardy was removed on 11/20/23. …
F604 citations in Missouri
Restraints · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F604 less often than its own record predicts
0.70 times the national share — cited less often here than elsewhere.
Of every deficiency written in Missouri in 2025, this is the portion that was F604.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F604 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 interview and record review, the facility failed to protect the resident's right to be free from physical restraint when staff physically restrained one resident (Resident #2) while assisting him/her back to the special care unit by holding the resident's arms behind his/her back resulting in the resident being upset and crying. The facility census was 77.Review of a facility policy titled Resident Rights, undated, showed the following:-It is the intent of the facility to promote and ensure the highest standards of conduct and reliability by its employees and consultants to in turn produce environments in the facility that promote the highest standards of care and security for our residents and families we serve;-The exercise of resident rights shall be free from restraint,… …
Based on interview and record review, the facility failed to ensure residents were free from physical restraints when staff tied a towel around the face of one resident (Resident #3) during a shower. The sample was 3. The census was 92. The Administrator was notified on 08/14/26 at 10:59 A.M. of the past non-compliance, which occurred on 08/04/26. All staff have been in-serviced on the facility's policy regarding restraints and addressing behaviors. The deficiency was corrected on 08/05/26. Review of the facility's Restraint Re-Education document, dated 08/04/26, showed:The facility is a restraint-free facility. This means cannot restrain resident by chemical or physical means. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.35% | 0.91× |
| 2024 | 0.19% | 0.51× |
| 2025 | 0.27% | 0.70× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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