Based on interview and record review, the facility failed to provide a safe and appropriate discharge for one sampled resident (Resident #3) out of three sampled residents when on 8/19/26 the facility dropped the resident off at the psychiatric hospital without proper notification. The facility census was 43 residents.Review of the facility's Transfer Discharge Policy, dated March 2025, showed:-Discharge referred to the movement of the resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility was not expected.-The following information was documented in the medical record and communicated to the receiving health care institution or provider:--Basis for the transfer;--Disposition of… …
F628 citations in Missouri
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F628 more often than its own record predicts
1.37 times the share F628 takes of citations nationally.
Of every deficiency written in Missouri in 2025, this is the portion that was F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F628 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, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #22, #38, and #49) out of three sampled residents. The facility census was 50.1. Review of the facility's policy titled, Bed Hold Policy Guidelines, undated, showed the facility will notify residents and/or their representative of the bed hold policy guidelines. The bed hold notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. …
What else Missouri surveyors cite →
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