Based on observation, interview and record review, the facility failed to provide treatment and behavioral health services for three sampled residents (Resident #4, Resident #7, and Resident #3) who had known behavioral health history and mental health diagnoses. The facility staff failed to implement a PASRR for Resident #4 and failed to create a plan of care for Resident #3 and Resident #4 to provide interventions for behaviors. The facility failed to transcribe, order, and administer Resident #4's psychotropic medications from [DATE] - [DATE] followed by an escalation of aggressive behaviors. …
F742 citations in Missouri
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F742 more often than its own record predicts
1.98 times the share F742 takes of citations nationally.
Of every deficiency written in Missouri in 2025, this is the portion that was F742.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F742 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 develop and implement meaningful interventions, including non-pharmacological interventions and alternate strategies, to ensure residents on the secured locked unit were not witness to or personally affected by one resident's (Resident #5's) known, sexually inappropriate behaviors when Resident #5 made sexual comments to other residents, exposed his/her genitals to residents, and rubbed his/her genitals on other residents. Residents were upset by Resident #5's actions. The facility failed to investigate an incident involving three residents (Resident #3, #5 and #6) to identify and address the root cause for their behaviors after the residents intimidated and verbally threatened to harm one resident (Resident #7). …
Based on interview and record review, the facility failed to ensure one resident (Resident #4), with a diagnosis of a traumatic brain injury (damage to the brain caused by an external physical force, such as a violent blow or bump or jolt to the head which disrupts normal brain function and ranges from mild to severe), in a review of 11 sampled residents, received appropriate treatment and services to attain their highest practicable mental and psychosocial well-being. Staff failed to implement individualized interventions based on the resident's behavioral symptoms and underlying causes and to communicate these interventions to staff in order to address the resident's verbally aggressive behaviors directed towards his/her previous roommate (Resident #5). …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.29% | 2.61× |
| 2024 | 0.33% | 2.64× |
| 2025 | 0.24% | 1.98× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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