Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the residents' needs in the event of an emergency for two residents (Residents #25 and #157), in a review of 17 sampled residents. The residents' care plans directed for four staff to lower the resident to the ground with a sling and drag the residents out of the building to safety on a lift pad in the event on an emergency evacuation. The facility staffing showed three or less staff worked on the night shift on seven days between 7/12/24 and 8/26/24. Insufficient staff to evacuate the resident had the potential to cause serious injury, harm or death in the event of an emergency requiring an emergency evacuation. …
F725 citations in Missouri
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F725 more often than its own record predicts
1.20 times the share F725 takes of citations nationally.
Of every deficiency written in Missouri in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F725 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 provide sufficient nursing staff to meet the needs of four residents (Resident #2, #3, #4 and #1) in a review of 10 sampled residents to answer call lights and check and change residents in a timely manner. Resident #2, normally continent of bowel and bladder, and requiring staff assistance to use the bathroom, turned on his/her call light and requested staff assist him/her out of bed as he/she needed to use the bathroom. Staff did not respond for three hours, and the resident was incontinent of bladder and bowel. The resident laid in urine and feces. …
Based on interview and record review, the facility failed to ensure adequate staff were present in the facility on the night shift between 07:53 P.M to 08:30 P.M. on 8/16/26. This had the potential to affect all residents within the facility. The facility census was 58.Review of the facility policy titled Sufficient Staff Policy revised on 05/18/24, showed:-It is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and-The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. 1. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.67% | 0.83× |
| 2024 | 0.82% | 1.03× |
| 2025 | 0.93% | 1.20× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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