| Facility failed to meet the following Requirement(s): | Corrected Date | Level of Harm | Residents Affected |
| §483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.35(d) Requirement for facility hiring and use of nurse aides-
§483.35(d)(1) General rule.
A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless-
(i) That individual is competent to provide nursing and nursing related services; and
(ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §483.151 through §483.154; or
(B) That individual has been deemed or determined competent as provided in §483.150(a) and (b).
§483.35(d)(2) Non-permanent employees.
A facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements in paragraphs (d)(1)(i) and (ii) of this section.
§483.35(d)(3) Minimum Competency
A facility must not use any individual who has worked less than 4 months as a nurse aide in that facility unless the individual-
(i) Is a full-time employee in a State-approved training and competency evaluation program;
(ii) Has demonstrated competence through satisfactory participation in a State-approved nurse aide training and competency evaluation program or competency evaluation program; or
(iii) Has been deemed or determined competent as provided in §483.150(a) and (b). |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.35(d) Requirement for facility hiring and use of nurse aides-
§483.35(d)(1) General rule.
A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless-
(i) That individual is competent to provide nursing and nursing related services; and
(ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §483.151 through §483.154; or
(B) That individual has been deemed or determined competent as provided in §483.150(a) and (b).
§483.35(d)(2) Non-permanent employees.
A facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements in paragraphs (d)(1)(i) and (ii) of this section.
§483.35(d)(3) Minimum Competency
A facility must not use any individual who has worked less than 4 months as a nurse aide in that facility unless the individual-
(i) Is a full-time employee in a State-approved training and competency evaluation program;
(ii) Has demonstrated competence through satisfactory participation in a State-approved nurse aide training and competency evaluation program or competency evaluation program; or
(iii) Has been deemed or determined competent as provided in §483.150(a) and (b). |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.35(d) Requirement for facility hiring and use of nurse aides-
§483.35(d)(1) General rule.
A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless-
(i) That individual is competent to provide nursing and nursing related services; and
(ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §483.151 through §483.154; or
(B) That individual has been deemed or determined competent as provided in §483.150(a) and (b).
§483.35(d)(2) Non-permanent employees.
A facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements in paragraphs (d)(1)(i) and (ii) of this section.
§483.35(d)(3) Minimum Competency
A facility must not use any individual who has worked less than 4 months as a nurse aide in that facility unless the individual-
(i) Is a full-time employee in a State-approved training and competency evaluation program;
(ii) Has demonstrated competence through satisfactory participation in a State-approved nurse aide training and competency evaluation program or competency evaluation program; or
(iii) Has been deemed or determined competent as provided in §483.150(a) and (b). |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.45(f) Medication Errors.
The facility must ensure that its-
§483.45(f)(1) Medication error rates are not 5 percent or greater; |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.45(f) Medication Errors.
The facility must ensure that its-
§483.45(f)(1) Medication error rates are not 5 percent or greater; |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.45(f) Medication Errors.
The facility must ensure that its-
§483.45(f)(1) Medication error rates are not 5 percent or greater; |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Few |
| §483.60(d) Food and drink
Each resident receives and the facility provides-
§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;
§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.60(d) Food and drink
Each resident receives and the facility provides-
§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;
§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.60(d) Food and drink
Each resident receives and the facility provides-
§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;
§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §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. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §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. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §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. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §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 §483.70(e) 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. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §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 §483.70(e) 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. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §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 §483.70(e) 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. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. |
8/23/2019
| No actual Harm with potential for More than minimal harm that is not immediate jeopardy | Some |
| Facilities shall conduct at least annual in-service education for nursing personnel including training in restorative nursing. This training by a registered nurse or qualified therapist shall include: turning and positioning for the bedridden resident, range of motion (ROM) exercises, ambulation assistance, transfer procedures, bowel and bladder retraining and self-care activities of daily living. II/III
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8/23/2019
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| The facility must develop and implement policies and procedures which ensure employees are screened to identify communicable diseases and ensure that employees diagnosed with communicable diseases do not expose residents to such diseases. The facility ' s policies and procedures must comply with the Missouri Department of Health ' s regulations pertaining to communicable diseases, specifically 19 CSR 20-20.010 through 19 CSR 20-20.100, as amended. II
|
8/23/2019
| | |
| Nursing assistants employed after January 1, 1980, shall have completed mandatory training as required by section 198.082, RSMo, or be enrolled in the course and functioning under the supervision of a state approved instructor of clinical supervisor as part of the one hundred (100) hours of on-the-job training. The person enrolled shall have successfully completed the course and become certified within one (1) year of employment with a licensed-only facility or within four (4) months of employment with a facility certified under Title XVIII or Title XIX if he or she is to remain employed in the facility as a nursing assistant. II
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8/23/2019
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| There shall be a safe and effective system of medication distribution, administration, control and use. I/II
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8/23/2019
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| Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. I/II
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8/23/2019
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| Taking into consideration the resident ' s preferences, residents shall be well-groomed and dressed appropriately for the time of day, the environment and any identified medical conditions. II/III
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8/23/2019
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| Residents shall be cared for by using acceptable infection control procedures to prevent the spread of infection. The facility shall make a report to the division within seven (7) days if a resident is diagnosed as having a communicable disease, as determined by the Missouri Department of Health and listed in the Code of State Regulations pertaining to communicable diseases, specifically 19 CSR 20-20.020, as amended. I/II
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8/23/2019
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| Effective measures intended to minimize the presence of rodents, flies, cockroaches and other insects on the premises shall be utilized. The premises shall be kept in such condition as to prevent the harborage or feeding of insects or rodents. II/III
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8/23/2019
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| The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III
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8/23/2019
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| At time of service to the resident, food shall be at least one hundred twenty degrees Fahrenheit (120°F) or forty-five degrees Fahrenheit (45°F) or below. II/III
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8/23/2019
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Missouri Department of Health & Senior Services