| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
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| §483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| § 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. |
4/17/2025
| Immediate Jeopardy to Resident Health or Safety | Few |
| § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.25(k) Pain Management.
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. |
4/17/2025
| Actual Harm that is not imediate jeopardy | Few |
| The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors. |
3/3/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.60(i) Food safety requirements.
The facility must -
§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.
§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.70(m) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.
§483.70(m)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.
§483.70(m)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;
§483.70(m)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.
§483.70(m)(4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.
§483.70(m)(5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k). |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Many |
| §483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;
§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.
§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:
§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;
§483.80(b)(2) Be qualified by education, training, experience or certification;
§483.80(b)(3) Work at least part-time at the facility; and
§483.80(b)(4) Have completed specialized training in infection prevention and control. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Many |
| §483.95 Training Requirements
A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at § 483.71. Training topics must include but are not limited to- |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Many |
| §483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Many |
| §483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Many |
| §483.95(f) Compliance and ethics.
The operating organization for each facility must include as part of its compliance and ethics program, as set forth at §483.85-
§483.95(f)(1) An effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program.
§483.95(f)(2) Annual training if the operating organization operates five or more facilities. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Many |
| §483.95(g) Required in-service training for nurse aides.
In-service training must-
§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.
§483.95(g)(2) Include dementia management training and resident abuse prevention training.
§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.71 and may address the special needs of residents as determined by the facility staff.
§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. |
4/17/2025
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Many |
Missouri Department of Health & Senior Services