Based on observation, interview, and record review, the facility failed to follow a physician order to apply the resident's lumbosacral orthosis (LSO) back brace prior to assisting the resident into a sitting position causing the resident to yell out in pain. This affected one of three sampled resident's. The facility census was 39.Review of the facility policy titled Pain Management, dated 05/01/25, showed:-The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents; goals and preferences;-In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or… …
F658 citations in Missouri
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F658 more often than its own record predicts
2.46 times the share F658 takes of citations nationally.
Of every deficiency written in Missouri in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F658 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, facility staff failed to document they completed physician ordered skin assessments for three residents (Resident #1, #2 and #3) of three sampled residents. The facility census was 73.The administrator was notified on 08/26/26 of past Non-Compliance which occurred 07/03/26 to 8/21/26, when staff were in-serviced on the facility's policies on completing physician ordered weekly skin assessments and timely documentation of those assessments. 1. Review of the facility's policy, Resident Examination and Assessment, dated 03/12, showed the purpose of the procedure is to examine and assess the resident for any abnormalities in health status. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 3.47% | 2.17× |
| 2024 | 3.30% | 2.01× |
| 2025 | 4.38% | 2.46× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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