| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| Fire Drills and Emergency Preparedness.
(B) The plan shall include, but is not limited to, the following:
1. A phased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to total building evacuation. This phased response part of the plan shall be consistent with the direction of the local fire unit or state fire marshal and appropriate for the fire or emergency;
2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and a floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge;
3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building;
4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks;
5. Procedures for the safety and comfort of residents evacuated;
6. Staffing assignments;
7. Instructions for staff to call the fire department or other outside emergency services;
8. Instructions for staff to call alternative resource(s) for housing residents, if necessary;
9. Administrative staff responsibilities; and
10. Designation of a staff member to be responsible for accounting for all residents ' whereabouts. II/III
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7/15/2025
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| Fire Drills and Emergency Preparedness.
(D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/III
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7/15/2025
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| Complete Fire Alarm Systems.
(E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II
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7/15/2025
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| The facility ' s current license shall be posted in a conspicuous place and notices provided to the facility by the department granting exception(s) to regulatory requirements shall be posted alongside of the facility ' s license. III
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7/15/2025
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| The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II
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7/15/2025
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| The administrator/manager shall maintain on the premises an individual personnel record on each facility employee, which shall include the following:
(E) Documentation of experience and education including for positions requiring licensure or certification, documentation evidencing competency for the position held, which includes copies of current licenses, transcripts when applicable, or for those individuals requiring certification, such as level I medication aides (LIMA), certified nurse aides, certified medication technicians (CMT) and insulin administration aides; printing the Web Registry search results page available at www.dhss.mo.gov/cnaregistry shall meet the requirements of the employer ' s check regarding valid certification: III
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7/15/2025
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| Residents admitted or readmitted to the facility shall have an admission physical examination by a licensed physician. Documentation should be obtained prior to admission but shall be on file not later than ten (10) days after admission and shall contain information regarding the resident ' s current medical status and any special orders or procedures which should be followed. If the resident is admitted directly from a hospital or another long-term care facility and is accompanied on admission by a report which reflects his/her current medical status, an admission physical will not be required. II/III
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7/15/2025
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| Self-control of prescription medication by a resident may be allowed only if approved in writing by the resident ' s physician and allowed by facility policy. A resident may be permitted to control the storage and use of nonprescription medication unless there is a physician ' s written order or facility policy to the contrary. Written approval for self-control of prescription medication shall be rewritten as needed but at least annually and after any period of hospitalization. II/III
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7/15/2025
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| Influenza and pneumococcal polysaccharide immunizations may be administered per physician-approved facility policy after assessment for contraindications.
(A) The facility shall develop a policy that provides recommendations and assessment parameters for the administration of such immunizations. The policy shall be approved by the facility medical director for facilities having a medical director, or by each resident ' s attending physician for facilities that do not have a medical director, and shall include the requirements to:
1. Provide education regarding the potential benefits and side effects of the immunization to each resident or the resident ' s designee or legally authorized representative; II/III
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7/15/2025
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| A pharmacist or registered nurse shall review the medication regimen of each resident. This shall be done at least every three (3) months in a residential care facility. The review shall be performed in the facility and shall include, but shall not be limited to, indication for use, dose, possible medication interactions and medication/food interactions, contraindications, adverse reactions and a review of the medication system utilized by the facility. Irregularities and concerns shall be reported in writing to the resident ' s physician and to the administrator/manager. If after thirty (30) days, there is no action taken by a resident ' s physician and significant concerns continue regarding a resident ' s or residents ' medication order(s), the administrator/manager shall contact or recontact the physician to determine if he or she received the information and if there are any new instructions. II/III
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7/15/2025
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| The facility shall maintain a record in the facility for each resident which shall include the following:
(B) A review monthly or more frequently, if indicated, of the resident ' s general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III
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7/15/2025
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Missouri Department of Health & Senior Services