Based on observation, interview and record review, the facility failed to maintain equipment in safe operating condition. On 11/18/22 at approximately 11:00 A.M., two staff noticed they could not turn down the packaged terminal air conditioner (PTAC) unit in a resident room (Resident #3 and Resident #10). The staff did not report the problem to maintenance staff. On 11/19/22 at approximately 12:30 A.M., a fire occurred in the residents' room. Review of the facility's investigation summary showed they determined the cause of the fire was the PTAC unit. Review of the fire marshal investigation showed the final hypothesis on the origin of the fire was the lower right side of the PTAC unit in the residents' room. …
F908 citations in Missouri
Equipment in safe condition · Environmental Deficiencies
Keep all essential equipment working safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Missouri cites F908 less often than its own record predicts
0.70 times the national share — cited less often here than elsewhere.
Of every deficiency written in Missouri in 2025, this is the portion that was F908.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Missouri surveyors wrote
F908 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 and interview, the facility failed to maintain functioning elevators when on 8/3/26 the front elevator was nonfunctioning impacting all residents who use the elevators for meals and activities. The facility census was 82 residents.1. Observation on 8/3/26 at 10:30 A.M. showed the front elevator of the facility was posted out of service. During an interview on 8/3/26 at 2:00 P.M. the Administrator said:-He/She was aware the elevator being inoperable.-He/She did not know when someone would be there to fix the elevator.-The elevator broke down over the weekend, 8/1/26. Review of Resident #21's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 5/18/26 showed the resident was cognitively intact. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 0.09% | 0.19× |
| 2024 | 0.25% | 0.56× |
| 2025 | 0.32% | 0.70× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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