Based on interview and record review, the facility failed to ensure appropriate identification and timely treatment of a resident's broken femur and severe pain for one sampled resident (Resident #1) out of four sampled residents. On 05/30/26 at 11:12 P.M., the resident fell and had severe pain. The facility failed to perform pain assessments, did not provide any non-pharmacological pain relief, and the resident's pharmacological pain relief treatment was delayed until 05/31/26 around 7:00 A.M. X-Ray was not completed until 05/31/26 around 11:14 A.M. Facility staff did not notify the physician the resident's ordered pain medication was not sufficient for the resident's pain and the x-ray was delayed. The resident was transferred to the hospital on [DATE] at 12:34 P.M. …
F684 citations in Missouri
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F684 less often than its own record predicts
0.79 times the national share — cited less often here than elsewhere.
Of every deficiency written in Missouri in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F684 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 interviews and record reviews, the facility failed to ensure that one resident (Resident #1), who had a diagnosis of diabetes mellitus (DM, a metabolic disease) and end-stage renal disease (ESRD, chronic irreversible kidney failure), who was receiving dialysis (a medical treatment that filters waste, extra salt, and fluid from the blood when the kidneys stop working) in a review of six sampled residents, received treatment and care per the facility's hemodialysis policy, when staff did not complete a pre-dialysis assessment that included a blood sugar finger stick (BSFS), did not offer the resident food prior to leaving the facility when the resident said he/she was hungry, and did not communicate with staff of the dialysis center when the resident was left in the lobby of the… …
Based on observation, interview, and record review, facility staff failed to ensure each resident receives treatment as ordered when one resident (Resident #2) did not receive Tubi grips (elastic support bandage used to apply continuous compression and support to extremities) daily as ordered by the Physician. The facility also failed to ensure documentation of daily implementation of the orders within the Treatment Administration Record (TAR) to effectively track completion of treatment orders. The facility had a census of 55.Review of facility records showed the facility did not provide a policy regarding implementation of treatment orders. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 2.11% | 0.58× |
| 2024 | 2.60% | 0.65× |
| 2025 | 3.37% | 0.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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