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CODE OF STATE REGULATIONS 1ROBIN CARNAHAN (9/30/12)Secretary of State

Rules of

Department of Health andSenior Services

Division 30—Division of Regulation and LicensureChapter 85—Intermediate Care and Skilled

Nursing Facility

Title Page

19 CSR 30-85.012 Construction Standards for New Intermediate Care and Skilled NursingFacilities and Additions to and Major Remodeling of Intermediate Careand Skilled Nursing Facilities...............................................................3

19 CSR 30-85.022 Fire Safety and Emergency Preparedness Standards for New and ExistingIntermediate Care and Skilled Nursing Facilities........................................9

19 CSR 30-85.032 Physical Plant Requirements for New and Existing Intermediate Careand Skilled Nursing Facilities .............................................................14

19 CSR 30-85.042 Administration and Resident Care Requirements for New and ExistingIntermediate Care and Skilled Nursing Facilities ......................................16

19 CSR 30-85.052 Dietary Requirements for New and Existing Intermediate Care andSkilled Nursing Facilities...................................................................21

Title 19—DEPARTMENT OFHEALTH AND SENIOR SERVICESDivision 30—Division of Regulation and

LicensureChapter 85—Intermediate Care and

Skilled Nursing Facility

19 CSR 30-85.012 Construction Standardsfor New Intermediate Care and SkilledNursing Facilities and Additions to andMajor Remodeling of Intermediate Careand Skilled Nursing Facilities

PURPOSE: This rule establishes constructionstandards for new intermediate care andskilled nursing facilities and additions to andremodeling of intermediate care and skillednursing facilities.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.Therefore, the material which is so incorpo-rated is on file with the agency who filed thisrule, and with the Office of the Secretary ofState. Any interested person may view thismaterial at either agency’s headquarters orthe same will be made available at the Officeof the Secretary of State at a cost not toexceed actual cost of copy reproduction. Theentire text of the rule is printed here. Thisnote refers only to the incorporated by refer-ence material.

PUBLISHER’S NOTE: All rules relating tolong-term care facilities licensed by the Divi-sion of Aging are followed by a RomanNumeral notation which refers to the class(either class I, II or III) of standard as desig-nated in section 198.085.1, RSMo 1986.

(1) Plans and specifications shall be preparedfor the construction of all new intermediatecare and skilled nursing facilities and addi-tions to and remodeling of existing facilities.The plans and specifications shall be pre-pared in conformance with Chapter 327,RSMo, by a duly registered architect or reg-istered professional engineer. III

(2) The facility may submit schematic andpreliminary plans to the division showing thebasic layout of the building and the generaltypes of construction, mechanical and electri-cal systems. The facility may submit detailsbefore the larger and more complicated work-ing drawings and specifications so that neces-sary corrections can be easily made beforethe final plans are submitted. The facilityshall prepare and submit working drawings

and specifications, complete in all respects,for approval by the division. These plansshall cover all phases of the construction pro-ject, including site preparation; paving; gen-eral construction; mechanical work, includ-ing plumbing, heating, ventilating and airconditioning; electrical work; and all built-inequipment, including elevators, kitchenequipment and cabinet work. II/III

(3) Facilities shall begin construction onlyafter the plans and specifications havereceived the written approval of the division.Facilities shall then build in conformancewith the approved plans and specifications.The facility shall notify the division withinfive (5) days after construction begins. Ifconstruction of the project is not started with-in one (1) year after the date of approval ofthe plans and specifications are not complet-ed within a period of three (3) years, thefacility shall resubmit the plans to the divi-sion for its approval and shall amend them, ifnecessary, to comply with the then currentrules before construction work is started orcontinued. II/III

(4) The facility shall be located on an all-weather road and have easy access for vehic-ular traffic. III

(5) Facilities shall have access to local fireprotection. III

(6) The facility shall provide adequate roadsand walks within the lot lines to the mainentrance and service entrance. III

(7) In any new addition, an existing licensedfacility shall provide all required ancillaryservice areas, proportional to the number ofnew beds. However, for existing facilities,these support service areas may be reducedby the amount of existing areas that meet newfacility requirements. New support areasrequired in this project, whether they are toserve the new beds or the existing beds, shallcomply with the rules for new facilities. III

(8) Facilities shall have administrative andpublic areas as listed: business office, admin-istrator’s office (business office and adminis-trator’s office may be combined); director ofnurses’ office; lobby and waiting room (maybe combined); public restrooms for each sex;and public telephone. III

(9) The facility shall provide recreation,occupational therapy, activity and residents’dining space at a ratio of at least thirty (30)square feet for each resident. II

(10) Facilities shall provide a bulk storagearea consisting of a locked room, shelving,bins and large cans for storing long-term sup-plies of food and other dietary materialsabove the floor in a dry room with adequateventilation, cool, but not freezing. The bulkstorage area shall be one (1) square foot perbed, but in no case shall it be less than onehundred (100) square feet. III

(11) Facilities shall have dry short-term stor-age areas for daily food supplies and otherdietary materials. The dry short-term storagearea may include the space required for bulkstorage. III

(12) A facility shall provide a preparationarea for wrapping removal, vegetable clean-ing and peeling and meat cutting. III

(13) Facilities shall provide adequate cookingand baking areas. III

(14) A facility shall have a salad and sand-wich preparation area for the preparation ofcold foods. III

(15) Facilities shall provide a tray preparationand loading area for preparing trays for resi-dents’ food delivery and food cart loading. III

(16) A facility shall provide a pot and panwashing area consisting of a three (3)-com-partment sink with a double drainboard forthe washing of utensils during the food prepa-ration period. III

(17) Facilities shall have a dishwashing areaprovided with a soiled dish receiving counter,space for scraping with a garbage grinder,prerinse sink, counter for racking dishes,dishwasher, clean dish counter, dish rackstorage and an exhaust fan. II/III

(18) A facility shall have a dish storage areawith shelves adjacent to the tray preparationarea. III

(19) Facilities shall provide refrigerators ofadequate capacity in all kitchens and otherpreparation centers where perishable foodswill be stored. A minimum of two (2) sepa-rate sections or boxes shall be provided in themain kitchen; one (1) for meat and dairyproducts and one (1) for general storage. III

(20) The refrigerators’ compressors and evap-orators shall have sufficient capacity to main-tain temperatures of thirty-five degreesFahrenheit (35°F) in the meat and dairyboxes and forty degrees Fahrenheit (40°F) in


Chapter 85—Intermediate Care and Skilled Nursing Facility 19 CSR 30-85

the general storage boxes when the boxes arebeing used for those purposes. II

(21) These compressors shall be automatical-ly controlled. III

(22) Compressors, piping and evaporatorsshall be tested for leaks and capacity. Certifi-cation of these tests shall be made available tothe division. III

(23) A facility shall have an office area forplanning menus and food purchases next tothe dietary area. III

(24) Kitchen shall have handwashing sinks.III

(25) A facility shall have a janitor’s area,exposed or in a closet, in or near the kitchen,that contains a floor receptor or service sink.III

(26) A garbage removal area with garbageand trash cans located inconspicuously shallbe easily accessible from both the kitchen andthe service drive. III

(27) Housekeeping areas shall be provided aslisted: clean linen area, soiled linen area andlaundry area. II

(28) The facility shall have a designated phys-ical therapy area large enough to give reha-bilitative care to physically disabled resi-dents. This area shall be sized toaccommodate all equipment and activities inthe facility’s proposed physical therapy pro-gram. In no case shall this area be less thantwo hundred (200) square feet. III

(29) The facility shall provide the followingelements: treatment areas and equipment asdictated by the facility’s physical therapy pro-gram; a handwashing sink; an exercise area;storage for clean linen, supplies and equip-ment; a toilet room located in the physicaltherapy room or within the immediate area ofthe physical therapy department; and anoffice or sufficient space for the physicaltherapy director’s desk and file. The physicaltherapy area may be located adjacent to anoccupational therapy area and share any or allof the required elements providing that thesharing of elements conforms with the facili-ty’s therapy programs. III

(30) If there is a designated occupationaltherapy area, it shall be large enough toaccommodate all the equipment and activitiesin the facility’s proposed occupational thera-py program. When the facility locates physi-

cal therapy and occupational therapy in thesame area, there shall be a space that can beseparated from the rest of the area if ceram-ics, sculpture, minor woodwork and lightmechanical work are a part of the occupa-tional therapy program. III

(31) Facilities shall provide a maintenanceroom or area. II

(32) A facility shall provide an employees’dressing or locker room with separaterestrooms for each sex. III

(33) Facilities shall provide storage rooms aslisted: general storage—ten (10) square feetper bed for the first fifty (50) beds, plus eight(8) square feet per bed for the next twenty-five (25) beds, plus five (5) square feet perbed for any additional beds over seventy-five(75). No storage room shall be less than onehundred (100) square feet of floor space. Therequired residents’ clothes storage room andstorage for outdoor equipment may be includ-ed in the minimum area required for generalstorage. III

(34) A continuous system of unobstructedcorridors, referred to as required corridors,shall extend through the enclosed portion ofeach story of the building. These corridorswill connect all rooms and spaces with eachother and with all entrances, exit ways andelevators, with the following exceptions:work suites, such as the administrative suiteand dietary area, occupied primarily byemployed personnel may contain corridors oraisles as necessary, and will not be subject tothe rules applicable to required corridors.Areas may be open to this system as permit-ted by the 1985 edition of the Life SafetyCode, for those facilities with plans approvedon or before December 31, 1998. All facili-ties with plans submitted for approval on orafter January 1, 1999, shall comply with theprovisions of the 1997 Life Safety Code,incorporated by reference in this rule. II/III

(35) A facility shall provide a personal careroom with barber and beauty shop facilities.III

(36) There shall be an oxygen storage roomthat is surrounded by one (1)-hour rated con-struction with a powered or gravity vent tothe outside. II

(37) Facilities shall have one (1) or morenursing units. A nursing unit shall not exceeda maximum of sixty (60) resident beds. Eachnursing unit shall be a single floor continuousarea which does not require resident care

traffic to traverse other areas. A facility shallnot locate a resident room door more thanone hundred forty feet (140') from the nurs-es’ station and the dirty utility room. II

(38) Resident room area shall be a minimumof eighty (80) square feet per bed in multiplebed resident rooms, and one hundred (100)square feet per bed in one (1)-bed residentrooms. A continuous aisle not less than threefeet (3') wide shall be available around thefoot and along both sides of each bed. Facil-ities shall locate beds to avoid drafts, exces-sive heat and other residents discomforts.Typical minimum clear dimensions for thebed area in resident rooms shall be asfollows:1-Bed 10' 6" × 9' 3"2-Bed 10' 6" × 15' 6"3-Bed 10' 6" × 21' 9"4-Bed 18' 0" × 15' 6"

Heating units and handwashing sinks mayprotrude into this required space. II

(39) To provide for the isolation of a resi-dent(s) with a communicable disease(s), eachunit shall have at least two (2) private residentrooms provided with a separate roomequipped with a toilet and handwashing sinkto serve the isolation room only. III

(40) Each resident shall have a wardrobe,locker or closet. A clothes rod and shelf shallbe provided. III

(41) No room shall be occupied by more thanfour (4) beds. III

(42) No resident shall be housed in a room inwhich the outside grade line is more thanthree feet (3') above the floor level on thewindow side of the resident room for a dis-tance of at least fifteen feet (15') from theoutside wall of the resident room. The resi-dent rooms shall be outside rooms with min-imum window sizes as follows:

1-Bed 10 square feet2-Bed 16 square feet3-Bed 24 square feet4-Bed 32 square feet

These areas are for total window size includ-ing frames. III

(43) Each resident, without entering the gen-eral corridor area, shall have access to a toi-let room. III

(44) One (1) toilet room shall serve no morethan six (6) beds and no more than two (2)resident rooms. II/III

(45) The toilet room shall contain a watercloset and a lavatory. II

4 CODE OF STATE REGULATIONS (9/30/08) ROBIN CARNAHAN

Secretary of State

19 CSR 30-85—DEPARTMENT OF HEALTH ANDSENIOR SERVICES Division 30—Division of Regulation and Licensure

(46) If each resident room contains a hand-washing sink, the may omit the handwashingsink from a toilet room that serves adjacentresident rooms. When a handwashing sink islocated within the same room as the toilet,the minimum area of a room shall be thirty(30) square feet. If the room contains only atoilet, the minimum area of the room shall beeighteen (18) square feet. III

(47) Each nursing unit shall have a centrallylocated nurses’ work station with a workcounter and storage space for charts. Theentire counter shall have a four foot (4') dis-tance between the wall located behind thecounter and the edge of the counter nearestthe wall. III

(48) Facilities shall provide a medicine prepa-ration room next to each nurses’ station thathas at least sixty (60) square feet of useablefloor space. Facilities shall provide a speciallocked medication cabinet for storage of theClass II medications inside the locked medi-cation cabinet. If the outer cabinets are notlocked, the facility must provide a closer andhardware that cannot be left unlocked on thedoor to the medicine room. A facility is alsorequired to have the following in the medicineroom: a work counter, handwashing sink,under cabinet storage, a medicine refrigera-tor, adequate lighting and provisions forproper temperature control. II/III

(49) Each nursing unit shall have a clean util-ity room accessible directly from the nursingunit corridor and near enough to the nurses’station to facilitate control by the nurses. Thefloor and walls shall have impervious sur-faces. The facility shall provide this roomwith adequate lighting and heating, a hand-washing sink and at least one (1) locking cab-inet. II/III

(50) Each nursing unit shall have a dirty util-ity room which is accessible directly fromthe nursing unit corridor. The floor shall havean impervious surface and the walls shallhave impervious surfaces to a minimumheight of five feet (5') above the floor. Theroom shall be provided with adequate lightingand heating, a double sink, clinic sink and atleast one (1) locking cabinet. III

(51) Each nursing unit shall contain one (1)training or handicapped toilet per sex, eachwith a floor area of at least five feet by sixfeet (5' × 6'). This toilet may be located inthe central bath. III

(52) Each nursing unit shall have a separatebathroom for each sex. II

(53) Tubs shall be institutional-type, freestanding with a minimum of three feet (3')clearance from the wall on each side and fourfeet (4') at the end. The shower shall be aminimum of four feet (4') wide and of amplelength for a wheelchair resident. Thirty-inchby sixty-inch (30" × 60") Americans withDisability Act (ADA)-approved showers willbe accepted. The facility may replacerequired institutional-type tub(s) withwhirlpool tubs or other types of bathing fix-tures. III

(54) The aggregate number of tubs or show-ers or both shall not be less than one for eachfifteen (1:15) beds on each floor. II/III

(55) The facility shall provide a locked cabi-net in or near each bathroom for the storageof cleaning supplies. III

(56) Centralized bathing facilities shall havefixed partitions or fire-resistant curtains toprovide a private compartment for each watercloset, bathtub and shower. Curtains or doorsshall be installed on access openings. III

(57) Clean linen storage with adequate shelv-ing is required in each nursing unit. III

(58) Each nursing unit must have a stretcherand wheelchair parking area. III

(59) Equipment and supply storage isrequired in each nursing unit. III

(60) Required corridors shall be at least eightfeet (8') wide and shall be wider at elevatorsand other points of traffic concentration. Nopart of the area of any required corridor oraisle shall be counted as part of the requiredarea of any space adjacent to the corridor oraisle. II/III

(61) The width of stairways shall not be lessthan three feet eight inches (3' 8"). The widthshall be measured between handrails wherehandrails project more than three and one-half inches (3 1/2"). II/III

(62) Doors from sleeping and treatment areasthrough which residents will pass shall be atleast forty-four inches (44") wide. Doors tocentralized toilets, bathrooms, hair caresalons and small day rooms shall be at leastthirty-six inches (36") wide. Doors to indi-vidual toilets adjacent to resident rooms shallbe at least thirty-two inches (32") wide. II

(63) Exit doors shall swing outward. Doors torooms shall swing into the rooms they serve.Doors to small toilet rooms may swing out-

ward into the next room and, if they swinginward, they shall be equipped for emergencyaccess. No doors shall swing into requiredcorridors or aisles except doors to janitors’closets, linen closets or doors to similar smallspaces that are open only temporarily. II

(64) Ceilings shall be at least eight feet (8').Ceilings in corridors, storage rooms, toiletrooms and other minor rooms shall not beless than seven feet six inches (7' 6"). Sus-pended tracks, rails and pipes located in thenormal traffic path shall be at least six feeteight inches (6' 8") above the floor. III

(65) Drinking fountains shall be located in ornear the lobby and recreation area and in eachnursing unit. The fountain shall be accessibleto residents in wheelchairs. III

(66) Facilities with plans approved on orbefore December 31, 1998, shall complywith the American National Standards Inst-itute (ANSI) publication A117.1, 1971, Mak-ing Buildings and Facilities Accessible to, andUseable by, the Physically Handicapped. Allnew facilities whose plans were submitted tothe division on or after January 1, 1999, shallcomply with ANSI A117.1, 1992, MakingBuildings and Facilities Accessible to, andUseable by, the Physically Handicapped,incorporated by reference in this rule. III

(67) Handrails shall be provided on bothsides of all corridors and aisles used by resi-dents. Corridor handrails shall have endsreturn to the wall. III

(68) All stairways shall have handrails onboth sides. II

(69) Facilities shall provide grab bars orhandrails, secured in proper positions tofacilitate the bodily movements of residents,next to all bathtubs, within all showers and onat least one (1) side of all toilets. II

(70) Lavatories shall be positioned to beaccessible to wheelchair residents and shallnot have cabinets underneath or any otherunnecessary obstruction to the maneuverabil-ity of wheelchairs. III

(71) The facility shall provide mirrors in eachresident’s room or adjoining toilet room.Mirrors shall be at least three feet (3') highwith the bottom edge located no more thanthree feet four inches (3' 4") above the flooror the facility may use framed tilting mir-ror(s). III



(72) Facilities shall provide fire-resistantdivider curtains attached to the ceiling orwalls in all resident rooms other than privateor single bedrooms. A facility shall placethese divider curtains to provide completeprivacy for each bed. III

(73) All new facilities and additions to allareas of existing facilities which undergomajor remodeling, shall be of sufficientstrength in all their parts to resist all stressesimposed by dead loads, live loads and lateralor uplift forces such as wind, without exceed-ing, in any of the structural materials, theallowable working stresses established forthese materials by generally accepted goodengineering practice. II

(74) The following unit live loads shall be theminimum distributed live loads acceptable forthe occupancies listed:

(A) Facility bedrooms and all adjoiningservice rooms which compose a typical nurs-ing unit (except solariums and corridors)—forty pounds per square foot (40 psf); II

(B) Solariums, corridors in nursing unitsand all corridors above the first floor, exami-nation and treatment rooms, laboratories, toi-let rooms and locker rooms—sixty (60) psf;II

(C) Offices, conference room, library,kitchen, corridors and other public areas onfirst the floor—eighty (80) psf; II

(D) Stairways, laundry, large rooms usedfor dining, recreation or assembly areas andworkshops—one hundred (100) psf; II

(E) Records file room, storage and sup-ply—one hundred twenty-five (125) psf; II

(F) Mechanical equipment room—onehundred fifty (150) psf; II

(G) Roofs (except use increased valuewhere snow and ice may occur)—twenty (20)psf; and II

(H) Wind—as required by local conditionsbut not less than fifteen (15) psf. II

(75) For live loads of one hundred (100)pounds or less per square foot, the design liveload on any member supporting one hundredfifty (150) square feet or more may bereduced at the rate of eight hundredths of apercent (0.08%) per square foot of area sup-ported by the member, except that no reduc-tions shall be made for roof live loads or forlive loads of areas to be occupied as places ofpublic assembly. The reduction shall exceedneither “R”, as determined by the followingformula nor sixty percent (60%): II

D + LR = 100 × _______________

4.33 L

where

R = reduction in percent;D = dead load per square foot of area sup-ported by the member; andL = design live load per square foot of areasupported by the member.

(76) For live loads exceeding one hundred(100) psf, no reduction shall be made, exceptthat the design live loads on columns may bereduced twenty percent (20%). II

(77) Floor areas where partition positions aresubject to change shall be designed to supporta uniformly distributed load of twenty-five(25) psf in addition to all other loads. II

(78) Foundations shall rest on natural solidground or properly compacted fill and shallbe carried to a depth of not less than one foot(1') below the estimated frost line or shallrest on leveled rock or load-bearing pileswhen solid ground is not encountered. Foot-ings, piers and foundation walls shall be ade-quately protected against deterioration fromthe action of groundwater. A facility shalltake reasonable care to establish proper soilbearing values for the building site soil. If thebearing capacity of a soil is in question, arecognized load test may be used to deter-mine the safe bearing value. II

(79) All facilities with plans approvedbetween June 10, 1981 and December 31,1998, shall comply with the 1985 edition ofthe Life Safety Code, and all new facilitieswith plans approved on or after January 1,1999, shall comply with the 1997 edition ofthe Life Safety Code (National Fire ProtectionAssociation NFPA 101), which are incorpo-rated by reference in this rule. No provisionof the 1997 code will be enforced if it is morerestrictive than the code of original planapproval. Facilities may only use the firesafety evaluation system found in the 1995NFPA 101A, incorporated by reference inthis rule, if necessary to justify variance fromthe text of the Life Safety Code and not as aguide for the total design of a new facility. II

(80) Facilities with plans approved on orbefore December 31, 1998, shall complywith the fire-resistant rating of structural ele-ments equal to those required by the 1985Life Safety Code (NFPA 101). Facilities withplans approved on or after January 1, 1999,shall comply with the fire-resistant rating ofstructural elements equal to those required bythe 1997 Life Safety Code (NFPA 101),incorporated by reference in this rule. Allfacilities shall meet the following additionalrequirement: exterior walls less than thirtyfeet (30') from an adjacent building, proper-

ty line or parallel wing shall have a two(2)-hour fire-resistant rating. This distancemay be reduced to fifteen feet (15') if a one(1)-hour rated wall is provided with sprinklerprotection for each window. II

(81) Doors between rooms and the requiredcorridors shall not have louvres or transoms.They shall be one and three-fourths inches (1 3/4") solid-core wood doors or metaldoors with equivalent or greater fire-resis-tance. II

(82) Laundry and trash chutes, where used,shall be of fire-resistant material and installedwith a flushing ring, vent to atmosphere andfloor drain in the basement. Facilities shallprovide an automatic sprinkler at the top ofeach laundry and trash chute. Each floor shallhave a self-closing one and one-half (1 1/2)-hour B-label fire door that shall not open to acorridor. II

(83) Hardware on toilet room doors shall beoperable from both the inside and the outside.II

(84) The floors of toilets, baths, bedpanrooms, pantries, utility rooms and janitors’closets shall have smooth, waterproof sur-faces which are wear-resistant. The floors ofresidents’ rooms shall be smooth and easilycleaned. The floors of kitchens and foodpreparation areas shall be waterproof, grease-proof, smooth and resistant to heavy wear.II/III

(85) The walls of all rooms where food anddrink are prepared, served or stored shallhave a smooth surface with painted or equal-ly washable finish. At the base, they shall bewaterproof and free from spaces which mayharbor ants and roaches. The walls ofkitchens, sculleries, utility rooms, baths,showers, dishwashing rooms, janitors’ closetsand spaces with sinks shall have waterproofpainted, glazed or similar finishes to a pointabove the splash and spray line. III

(86) The ceilings of all sculleries, kitchensand other rooms where food and drink areprepared shall be painted with washablepaint. III

(87) All floor construction shall be complete-ly of noncombustible material regardless ofthe construction type of the building. II

(88) All new floor covering installed and usedin new and existing licensed facilities on or


Secretary of State




after January 1, 1999, shall be Class I in non-sprinklered buildings and Class II in sprin-klered buildings. Class I has a critical radi-ant flux of zero point forty-five (0.45) ormore watts per square centimeter when test-ed according to the 1995 NFPA 253, incor-porated by reference in this rule. Class II hasa critical radiant flux of zero pointtwenty-two (0.22) or more watts per squarecentimeter when tested according to the 1995NFPA 253. Those facilities who installednew floor covering on or before December31, 1998, shall comply with the requirementsof the 1978 edition of the NFPA 253. III

(89) A facility shall furnish and install theheating system, steam system, boilers andventilation to meet all requirements of localand state codes and NFPA regulations. II/III

(90) The building shall be heated by a two(2)-pipe steam system, a forced hot water sys-tem, a forced hot air system, a system of elec-trical heating elements or a combination oftwo (2) or more of these systems. No open

flame space heaters or space heaters receiv-ing combustion air from the heated spaceshall be used. Facilities shall not dependupon fireplaces for required heating. III

(91) The heating system shall be capable ofheating resident-occupied areas to a tempera-ture of eighty degrees Fahrenheit (80°F)(27°C) at the winter design temperature. Inspaces where radiant panel heating is used,facilities may reduce the temperature asrequired to maintain an equivalent comfortlevel. III

(92) The heating system shall have automaticcontrols adequate to provide comfortableconditions in all portions of the building at alltimes. III

(93) Neither the heating nor the ventilatingsystem shall require the circulation of airthrough openings in the required corridorpartitions except for the delivery of ventilat-ing air from corridors through each room

door at a velocity of not more than two hun-dred fifty feet (250') per minute when thedoor is closed and the space under it is notover one inch (1") in height. No louvres shallbe installed in doors in required corridor par-titions. II/III

(94) A facility with plans approved on orafter January 1, 1999, shall install an air-con-ditioning system, or individual room air-con-ditioning units, that meet all the 1996 NFPA90A requirements, incorporated by referencein this rule. The systems or units must becapable of maintaining resident-use areas ateighty-five degrees Fahrenheit (85°F)(29.4°C) at the summer design temperature.Those facilities with plans approved on orbefore December 31, 1998, shall complywith the NFPA 90A requirements as refer-enced in the 1985 Life Safety Code. II/III

(95) Ventilation requirements given in TableI—Ventilation Requirements shall be met.II/III

TABLE I VENTILATION REQUIREMENTSMinimum Air

Pressure Changes of Outdoor Minimum Total Air All Air ExhaustedRelationship to Air Per Hour Changes Per Hour Directly to Air Returned From

Area Designation Adjacent Areas Supplied to Room Supplied to Room Outdoors This Room

Patient Area Corridor P Optional 2 Optional Optional

Physical Therapy N 2 4 Optional OptionalOccupational Therapy N 2 4 Optional OptionalSoiled Work Roomor Soiled Holding N 2 10 Yes No

*Toilet Room N Optional 6 Yes NoBathroom N Optional 6 Yes NoJanitors’ Closet(s) N Optional 6 Yes No

Linen and TrashChute Room N Optional 6 Yes No

Food PreparationCenter E 2 6 Yes Optional

Warewashing Room N Optional 6 Yes NoDietary Day Storage V Optional 2 Yes NoLaundry, General V 2 6 Yes NoSoiled Linen Sortingand Storage N Optional 10 Yes No

P = PositiveN = NegativeE = EqualV = Variable

*Up to 75 cubic feet per minute (cfm) of make-up air for each patient room toilet may be supplied to the corridor and need not be supplieddirectly to the room.

NOTE: In the interest of energy conservation, energy saving design innovations that are not in strict conformance with these requirements,which do not adversely affect direct patient care, will be acceptable if approved in writing by the Division of Aging.

(96) The entire plumbing system and itsmaintenance and operation shall comply withthe requirements of all applicable local andstate codes including the requirements setforth in this rule and with the requirements ofthe 1987 National Plumbing Code, which isincorporated by reference in this rule. II/III

(97) Plumbing fixtures that require hot waterand are resident-accessible shall be suppliedwith water thermostatically controlled to pro-vide a water temperature of between one hun-dred twenty degrees Fahrenheit (120°F)(49°C) and one hundred five degrees Fahren-heit (105°F) (41°C) at the fixture or faucet.I/II

(98) The hot water heating equipment shallhave sufficient capacity to supply five (5) gal-lons (19 l) of water at one hundred twentydegrees Fahrenheit (120°F) (49°C) per hourper bed for nursing home fixtures or faucets,and eight (8) gallons (30 l) of water at onehundred sixty degrees Fahrenheit (160°F)(71.1°C) per hour per bed for kitchen andlaundry. The division may accept lessercapacities following submission of the calcu-lation for the anticipated demand of all fix-tures and equipment in the building. II

(99) Pipes shall be sized to supply water to allfixtures with a minimum pressure of fifteenpounds per square inch (15 psi) (1.02 atmo-spheres) at the top floor fixture during maxi-mum demand periods. All plumbing fixturesexcept water closets, urinals and drinkingfountains shall have both hot and cold watersupplies. III

(100) Facilities shall protect every supplyoutlet or connection to a fixture or applianceagainst back flow as provided by the 1987National Plumbing Code, incorporated byreference in this rule. All faucets to whichhoses can be attached, all spray fittings andall other fittings that could deliver water topoints below overflow lines, shall beequipped with vacuum breakers. II/III

(101) Wherever the usage of fixtures or appli-ances will permit, water supplied to all fix-tures, open tanks and equipment shall beintroduced through a suitable air gap betweenthe water supply and the flood level of thefixture. II

(102) Hot water circulating mains and risersshall be run from the hot storage tank to apoint directly below the highest fixture at theend of each branch main. III

(103) Where the building is higher than three(3) stories, each riser shall be circulated. III

(104) Water pipe sizes shall be equal to orgreater than those prescribed by the 1987National Plumbing Code, incorporated byreference in this rule. III

(105) All fixtures and equipment shall beconnected through traps to soil and waste pip-ing and to the sewer and they shall all beproperly trapped and vented to the outside. II

(106) Courts, yards and drives which do nothave natural drainage from the building shallhave catch basins and drains to low ground,storm-water system or dry wells. III

(107) Facilities where gas-fired equipment isto be installed for use on or after January 1,1999, shall provide and install all gas piping,fittings, tanks and specialties in compliancewith the 1996 NFPA 54, Installation of GasAppliances and Gas Piping, the 1995 NFPA58, Storage and Handling of LiquefiedPetroleum Gases, incorporated by referencein this rule, and the instructions of the gassupplier, except where more strict require-ments are stated. Facilities which installedgas-fired equipment on or before December31, 1998, shall ensure that the installationwas in compliance with the instructions andrequirements outlined in the NFPA 54 andNFPA 58 as referenced in the 1985 Life Safe-ty Code. Where liquefied petroleum gas(LPG) is used, the Missouri Department ofAgriculture also requires compliance with itsrules. II

(108) Where gas piping enters the buildingbelow grade, it shall have an outside vent asfollows: A concrete box, eighteen inches byeighteen inches (18" × 18") with three-inch(3") thick walls, of a height to rest on top ofthe entering gas pipe, and top of the box tocome within six inches (6") of top grade. Thebox shall be filled with coarse gravel. A one-inch (1") upright vent line shall be to one-half(1/2) the depth of the box and extend twelveinches (12") above top grade with a screenedU-vent looking down. The vent line is to beanchored securely to the building wall. II

(109) Facilities shall not install gas-firedequipment in any resident bedroom exceptthat through-wall gas heating units may beused if vented directly to the outside, takecombustion air directly from the outside andprovide a complete separation of the combus-tion system from the atmosphere of the occu-pied area. II

(110) In facilities where oxygen systems areinstalled on or after January 1, 1999, thefacilities shall install the oxygen piping, out-lets, manifolds, manifold rooms and storagerooms in accordance with the requirements ofthe 1993 NFPA 99, incorporated by referencein this rule. In facilities where oxygen sys-tems were installed on or before December31, 1998, facilities shall ensure that theinstallation was in compliance with NFPA 99as required and referenced in the 1985 LifeSafety Code. I/II

(111) The building sanitary drain system maybe cast iron, steel, copper or plastic ifinstalled in compliance with the NationalPlumbing Code, current edition. III

(112) Each main, branch main, riser andbranch to a group of fixtures of the water sys-tem shall be valved. III

(113) To prevent condensation, facilities shallcover cold water mains in occupied spaceswith approved vapor-proof insulation. III

(114) To prevent freezing, facilities shallinsulate all pipes in outside walls. III

(115) Facilities shall test soil, waste, vent anddrain lines according to the requirements ofthe 1987 National Plumbing Code, incorpo-rated by reference in this rule. The facilityshall make certification of these tests avail-able to the division. III

(116) After installation and before the nurs-ing home is operating, the facility shall disin-fect the entire water distribution system, bothhot and cold, and all connecting equipmentby one (1) of the methods described in the1987 National Plumbing Code, incorporatedby reference in this rule. III

(117) Water softeners, if used, shall be con-nected to the hot water supply only or con-nected so that water used for cooking anddrinking is not softened. III

(118) Facilities with plans approved on orafter January 1, 1999, shall ensure that theentire electrical system and its maintenanceand operation comply with the 1996 Nation-al Electrical Code, which is incorporated byreference in this rule. Facilities whose planswere approved on or before December 31,1998, shall comply with the National Electri-cal Code as referenced in the 1985 Life Safe-ty Code. II/III


Secretary of State


(119) Facilities shall adequately light alloccupied areas as required by the duties per-formed in that space. II/III

(120) Residents’ bedrooms shall have a mini-mum general illumination of ten (10) foot-candles, a night-light and a resident’s readinglight. The outlets for general illumination andnight-lights shall be switched at the door. III

(121) Each single-bed resident room shallhave at least two (2) duplex receptacles. Allmulti-bed resident rooms shall have at leastone (1) duplex receptacle at the head of eachbed plus one (1) additional duplex receptacle.Facilities shall not place duplex receptacles ina manner to cause an electrical shock hazard.III

(122) Facilities shall furnish lighting fixturesof a type suitable for the space for all lightingoutlets. III

(123) If ceiling lights are used in residents’rooms, they shall be of a type which are shad-ed or globed to minimize glare. III

(124) Facilities shall provide an electrically-powered nurses’ call system with indicatorlights at the corridor entrance of each bed-room. Audible signals and indicating panelsshall be located in each nurses’ station andutility room. Facilities shall provide signalbuttons at the head of each resident bed, ineach toilet room and in each bathroom. III

(125) Facilities shall provide night-lights inhallways, individual toilet rooms, stairwaysand resident rooms or adjacent toilet rooms.II

(126) A qualified electrician shall test andcertify the entire electrical system as being incompliance with the 1996 National ElectricalCode, incorporated by reference in this rule.In facilities whose plans were approved on orbefore December 31, 1998, the electricianshall test the system according to the stan-dards of the National Electrical Code as ref-erenced in the 1985 Life Safety Code. Facil-ities shall make this test certification availableto the division. III

(127) Facilities shall provide a complete,electrically-operated door alarm system thatis audible in the nurses’ station for all resi-dent-accessible exterior doors. III

(128) A facility shall have emergency light-ing for exits, stairs, corridors and nurses’ sta-tions. Facilities may provide this emergencylighting using an emergency generator or bat-

tery-operated lights rated at least one andone-half (1 1/2) hours. In facilities withplans approved on or after January 1, 1999,an emergency generator shall supply emer-gency power to life support systems asrequired by the 1993 NFPA 99, Health CareFacilities, incorporated by reference in thisrule. In facilities where plans were approvedon or before December 31, 1998, the electri-cal system shall comply to the standards ofthe National Electrical Code as referenced inthe 1985 Life Safety Code. III

(129) The elevator installations shall complywith all local and state codes, AmericanStandards Association Specification A17.1,1993 Safety Code for Elevators and Escala-tors, the 1996 National Electrical Code,incorporated by reference in this rule, and theminimum general standards as set forth inthis rule. In facilities whose plans wereapproved on or before December 31, 1998,the elevators shall comply with applicablelocal and state codes and the requirements setforth in the ASAS A17.1, Safety Code forElevators and Escalators, and the NationalElectrical Code as referenced in the 1985 LifeSafety Code. II

(130) Any facility with residents on one (1)or more floors above the first floor shall haveat least one (1) hydraulic or electric motordriven elevator. Facilities with a bed capacityfrom sixty-one to two hundred (61–200)above the first floor shall not have less thantwo (2) elevators. II

(131) Facilities with a bed capacity of fromtwo hundred to three hundred fifty (200—350) above the first floor shall have not lessthan three (3) elevators—two (2) passengerand one (1) service. II

(132) Inside cab dimensions of elevators shallbe not less than five feet four inches by eightfeet (5' 4" × 8') with a capacity of threethousand five hundred pounds (3,500 lbs.).Cab and shaft doors shall have no less thanthree feet ten inches (3' 10") clear opening.Elevators for which operators will not beemployed shall have automatic push-buttoncontrols, signal controls or dual controls foruse with or without the operator. Where two(2) push-button elevators are located togetherand where one (1) elevator serves more thanthree (3) floors and basement, they shall havecollective or signal control. III

(133) Facilities with plans approved on orafter January 1, 1999, shall have overspeedtests conducted on all elevator machines.Elevators will be tested for speed and load,

with and without loads, in both directions ascovered by the 1993 Safety Code for Eleva-tors and Escalators, incorporated by refer-ence in this rule. Facilities whose plans wereapproved on or before December 31, 1998,shall conduct overspeed tests in accordancewith applicable local and state codes and therequirements set forth in the ASAS A17.1,Safety Code for Elevators and Escalators, asreferenced in the 1985 Life Safety Code.Facilities shall make this test certificationavailable to the division. III

AUTHORITY: section 198.009, RSMo Supp.1998.* This rule originally filed as 13 CSR15-14.012. Original rule filed July 13, 1983,effective Oct. 13, 1983. Amended: Filed Aug.1, 1988, effective Nov. 11, 1988. Amended:Filed May 11, 1998, effective Dec. 30, 1998.Emergency amendment filed May 12, 1999,effective May 22, 1999, expired Feb. 24,2000. Amended: Filed July 13, 1999, effec-tive Jan. 30, 2000. Moved to 19 CSR 30-85.012, effective Aug. 28, 2001.

*Original authority: 198.009, RSMo 1979, amended1993, 1995.

19 CSR 30-85.022 Fire Safety and Emer-gency Preparedness Standards for Newand Existing Intermediate Care andSkilled Nursing Facilities

PURPOSE: This rule establishes fire-safetyand emergency preparedness requirements fornew and existing intermediate care andskilled nursing facilities.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.This material as incorporated by reference inthis rule shall be maintained by the agency atits headquarters and shall be made availableto the public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference mate-rial. The entire text of the rule is printedhere.

AGENCY NOTE: All rules relating to long-term care facilities licensed by the Depart-ment of Health and Senior Services are fol-lowed by a Roman Numeral notation whichrefers to the class (either class I, II, or III) ofstandard as designated in section 198.085,RSMo 2000.

(1) Definitions. For the purpose of this rule,the following definitions shall apply:



(A) Accessible spaces—shall include allrooms, halls, storage areas, basements, attics,lofts, closets, elevator shafts, enclosed stair-ways, dumbwaiter shafts, and chutes;

(B) Area of refuge—a space located in orimmediately adjacent to a path of travel lead-ing to an exit that is protected from theeffects of fire, either by means of separationfrom other spaces in the same building or itslocation, permitting a delay in evacuation. Anarea of refuge may be temporarily used as astaging area that provides some relative safe-ty to its occupants while potential emergen-cies are assessed, decisions are made, and ifapplicable, evacuation has begun;

(C) Major renovation—shall include thefollowing:

1. Addition of any room(s), accessibleby residents, that either exceeds fifty percent(50%) of the total square footage of the facil-ity or exceeds four thousand five hundred(4,500) square feet;

2. Repairs, remodeling, or renovationsthat involve more than fifty percent (50%) ofthe building;

3. Repairs, remodeling, or renovationsthat involve more than four thousand fivehundred (4,500) square feet of a smoke sec-tion; or

4. If the addition is separated by two-(2-) hour fire-resistant construction, only theaddition portion shall meet the requirementsfor an NFPA 13, 1999 edition, sprinkler sys-tem, unless the facility is otherwise requiredto meet NFPA 13, 1999 edition; and

(D) Concealed spaces—shall include areaswithin the building that cannot be occupied orused for storage.

(2) General Requirements.(A) All National Fire Protection Associa-

tion (NFPA) codes and standards cited in thisrule: NFPA 10, Standard for Portable FireExtinguishers, 1998 edition; NFPA 13, Stan-dard for the Installation of Sprinkler Systems,1999 edition; NFPA 96, Standard for Venti-lation Control and Fire Protection of Com-mercial Cooking Operations, 1998 edition;NFPA 99, Standard for Health Care Facili-ties, 1999 edition; NFPA 101, The Life Safe-ty Code, 2000 edition; NFPA 72, NationalFire Alarm Code, 1999 edition; NFPA 25,Standard for the Inspection, Testing, andMaintenance of Water-Based Fire ProtectionSystems, 1998 edition; NFPA 253, StandardMethod of Test of Surface Burning Charac-teristics of Building Materials, 2000 edition;NFPA 701, Standard Methods of Fire Testsfor Flame Propagation of Textiles and Films,1999 edition; NFPA 211, Chimneys, Fire-places, Vents and Solid Fuel-Burning Appli-ances, 2000 edition; and NFPA 101A, Guide

to Alternative Approaches to Life Safety,2001 edition, are incorporated by reference inthis rule and available for purchase from theNational Fire Protection Agency, 1 Battery-march Park, Quincy, MA 02269-9101;www.nfpa.org; by telephone at (617) 770-3000 or 1-800-344-3555. This rule does notincorporate any subsequent amendments oradditions to the materials listed above.

(B) This rule does not prohibit facilitiesfrom complying with standards set forth innewer editions of the incorporated by refer-ence material listed in subsection (2)(A) ofthis rule if approved by the department.

(C) The department shall have the right ofinspection of any portion of a building inwhich a licensed facility is located unless theunlicensed portion is separated by two- (2-)hour fire-resistant construction. I/II

(D) Facilities shall not use space understairways to store combustible materials. I/II

(E) No section of the building shall presenta fire hazard. I/II

(F) All facilities shall notify the depart-ment immediately after the emergency isaddressed if there is a fire in the facility orpremises and shall submit a complete writtenfire report to the department within seven (7)days of the fire, regardless of the size of thefire or the loss involved. II/III

(G) Following the discovery of any fire, thefacility shall monitor the area and/or thesource of the fire for a twenty-four- (24-)hour period. This monitoring shall include, ata minimum, hourly visual checks of the area.These hourly visual checks shall be docu-mented. I/II

(H) All electrical appliances shall beUnderwriters’ Laboratories (UL) or FactoryMutual (FM)-approved, shall be maintainedin good repair, and no appliances or electri-cal equipment shall be used which emitfumes or which could in any other way pre-sent a hazard to the residents. I/II

(3) All openings that could permit the passageof fire, smoke, or both, between floors shallbe fire-stopped with a suitable noncom-bustible material. II/III

(4) Hazardous areas shall be separated byconstruction of at least one- (1-) hour fire-resistant construction. Hazardous areas maybe protected by an automatic sprinkler systemin lieu of a one- (1-) hour rated fire-resistantconstruction. When the sprinkler option ischosen, the areas shall be separated fromother spaces by smoke-resistant partitions anddoors. The doors shall be self-closing orautomatic closing. II

(5) The storage of any unnecessary com-bustible materials in any part of a building inwhich a licensed facility is located is prohib-ited. No section of the building shall presenta fire hazard. I/II

(6) Oxygen storage shall be in accordancewith NFPA 99, 1999 edition. Facilities shalluse permanent racks or fasteners to preventaccidental damage or dislocation of oxygencylinders. Safety caps shall remain intactexcept where a cylinder is in actual use orwhere the regulator has been attached and thecylinder is ready for use. Individual oxygencylinders in use or with an attached regulatorshall be supported by cylinder collars or bystable cylinder carts. II/III

(7) Each nursing unit may maintain only one(1) emergency-use oxygen tank in a readilyaccessible unit area. II

(8) Fire Extinguishers.(A) Fire extinguishers shall be provided at

a minimum of one (1) per floor, so that thereis no more than seventy-five feet (75') traveldistance from any point on that floor to anextinguisher. I/II

(B) All new or replacement portable fireextinguishers shall be ABC-rated extinguish-ers, in accordance with the provisions ofNFPA 10, 1998 edition. A K-rated extin-guisher or its equivalent shall be used in lieuof an ABC-rated extinguisher in the kitchencooking areas. II

(C) Fire extinguishers shall have a rating ofat least—

1. Ten pounds (10 lbs.), ABC-rated orthe equivalent, in or within fifteen feet (15')of hazardous areas as defined in 19 CSR 30-83.010; II and

2. Five pounds (5 lbs.), ABC-rated orthe equivalent, in other areas. II

(D) All fire extinguishers shall bear thelabel of the UL or the FM Laboratories andshall be installed and maintained in accor-dance with NFPA 10, 1998 edition. Thisincludes the documentation and dating of amonthly pressure check. II/III

(9) Facilities shall provide every cookingrange with a range hood and approved rangehood extinguishing system installed, tested,and maintained in accordance with NFPA 96,1998 edition. The range hood and its extin-guishing system shall be certified at leasttwice annually in accordance with NFPA 96,1998 edition. II/III

(10) Complete Fire Alarm Systems.(A) Facilities shall have a complete fire

alarm system installed in accordance with


Secretary of State


NFPA 101, Section 18.3.4, 2000 edition.The complete fire alarm system shall auto-matically transmit to the fire department, dis-patching agency, or central monitoring com-pany. The complete fire alarm system shallinclude visual signals and audible alarms thatcan be heard throughout the building and amain panel that interconnects all alarm-acti-vating devices and audible signals in accor-dance with NFPA 72, 1999 edition. Manualpull stations shall be installed at or near eachrequired nurse/attendant’s station and eachrequired exit. Smoke detectors shall be inter-connected to the complete fire alarm system.Specific minimum requirements relating tothe interconnected smoke detectors are foundin subsections (10)(I) and (10)(J) of this rule.I/II

(B) All facilities shall test and maintain thecomplete fire alarm system in accordancewith NFPA 72, 1999 edition. I/II

(C) All facilities shall have inspections andwritten certifications of the complete firealarm system completed by an approved qual-ified service representative in accordancewith NFPA 72, 1999 edition, at least annual-ly. I/II

(D) The complete fire alarm system shallbe activated by all of the following: sprinklersystem flow alarm, smoke detectors, heatdetectors, manual pull stations, and activationof the range hood extinguishment system.II/III

(E) Facilities shall test by activating thecomplete fire alarm system at least once amonth. II/III

(F) Facilities shall maintain a record of thecomplete fire alarm system tests, inspectionsand certifications required by subsections(10)(B), (10)(C), and (10)(E) of this rule. III

(G) Upon discovery of a fault with thecomplete fire alarm system, the facility shallcorrect the fault. I/II

(H) When a complete fire alarm system isto be out-of-service for more than four (4)hours in a twenty-four- (24-) hour period, thefacility shall immediately notify the depart-ment and the local fire authority and imple-ment an approved fire watch in accordancewith NFPA 101, 2000 edition, until the firealarm system has returned to full service. I/II

(I) All facilities shall have smoke detectorsinterconnected to the complete fire alarm sys-tem in all corridors and spaces open to corri-dors. Smoke detectors shall be no more thanthirty feet (30') apart with no point on theceiling more than twenty-one feet (21') froma smoke detector. I/II

(J) Facilities that have a sprinkler systemexemption shall have smoke detectors inter-connected to the complete fire alarm systemin all accessible spaces within the facility as

required by NFPA 72, 1999 edition. Smokedetectors shall be no more than thirty feet(30') apart with no point on the ceiling morethan twenty-one feet (21') from a smokedetector. Smoke detectors shall not beinstalled in areas where environmental influ-ences may cause nuisance alarms. Such areasinclude, but are not limited to, kitchens, laun-dries, bathrooms, mechanical air handlingrooms, and attic spaces. In these areas, heatdetectors interconnected to the complete firealarm system shall be installed. Bathroomsnot exceeding fifty-five (55) square feet andclothes closets, linen closets, and pantries notexceeding twenty-four (24) square feet areexempt from having any detection device ifthe walls and ceilings are surfaced with limit-ed-combustible or noncombustible materialas defined in NFPA 101, 2000 edition. Con-cealed spaces of noncombustible or limited-combustible construction are not required tohave detection devices. These spaces mayhave limited access but cannot be occupied orused for storage. I/II

(K) For each facility not having a sprinklersystem exemption, each resident room or anyroom designated for sleeping shall beequipped with at least one (1) battery-poweredsmoke alarm installed, tested, and maintainedin accordance with manufacturer’s specifica-tions. In addition, the facility shall beequipped with interconnected heat detectorsinstalled, tested, and maintained in accor-dance with NFPA 72, 1999 edition, withdetectors in all areas subject to nuisancealarms, including, but not limited to, kitchens,laundries, bathrooms, mechanical air handlingrooms, and attic spaces. I/II

1. The facility shall maintain a writtenrecord of the monthly testing and batterychanges. The written records shall beretained for one (1) year. I/II

2. Upon discovery of a fault with anydetector or alarm, the facility shall correctthe fault. I/II

(11) Sprinkler System.(A) All facilities shall have inspections and

written certifications of the sprinkler systemcompleted by an approved qualified servicerepresentative in accordance with NFPA 25,1998 edition. The inspections shall be inaccordance with the provisions of NFPA 25,1998 edition, with certification at least annu-ally by a qualified service representative. I/II

(B) All facilities licensed prior to August28, 2007, that were not required to have acomplete sprinkler system in accordance withNFPA 13 shall have until December 31,2012, to comply with NFPA 13, 1999 edi-tion. I/II

1. Exemptions shall be granted if the

facility presents evidence in writing from acertified sprinkler system representative orlicensed engineer that the facility is unable toinstall an approved NFPA 13, 1999 edition,system due to the unavailability of the watersupply. I/II

(C) Facilities that have a sprinkler systeminstalled prior to August 28, 2007, shallinspect, maintain, and test these systems inaccordance with the requirements in effectfor such facilities on August 27, 2007. I/II

(D) Facilities licensed on or after August28, 2007, or any section of a facility in whicha major renovation has been completed on orafter August 28, 2007, shall install and main-tain a complete sprinkler system in accor-dance with NFPA 13, 1999 edition. I/II

(E) When a sprinkler system is to be out-of-service for more than four (4) hours in atwenty-four- (24-) hour period, the facilityshall immediately notify the department andthe local fire authority and implement anapproved fire watch in accordance withNFPA 101, 2000 edition, until the sprinklersystem has returned to full service. I/II

(12) Each floor of an existing licensed facili-ty shall have at least two (2) unobstructedexits remote from each other. One (1) of therequired exits in an existing multi-story facil-ity must be an outside stairway or an enclosedstair that is separated by one- (1-) hour con-struction from each floor and has an exitleading directly outside at grade level. One(1) exit may lead to a lobby with exit facili-ties to the ground level outside instead ofleading directly to the outside. The lobbyshall have at least a one- (1-) hour fire-ratedseparation from the remainder of the exitingfloor. I/II

(13) If facilities have outside stairways, theyshall be substantially constructed to supportresidents during evacuation. These stairwaysshall be protected or cleared of ice and snow.Stairways shall be of sturdy constructionusing at least two-inch (2") lumber and shallbe continuous to ground level. All treads andrisers shall be of the same height and widththroughout the entire stairway, not includinglandings. II/III

(14) Fire escapes added to existing buildings,whether interior or exterior, shall have atleast a minimum thirty-six-inch (36") width,eight-inch (8") maximum risers, a nine-inch(9") minimum tread, no winders, a maximumheight between landings of twelve feet (12'),minimum landing dimensions of forty-fourinches (44"), landings at each exit door, andhandrails on both sides. Exit(s) to fireescapes shall be at least thirty-six inches



(36") wide, and the fire-escape door shallswing outward. All treads and risers shall beof the same height and width throughout theentire stairway, not including landings. II/III

(15) Facilities with three (3) or more floorsshall comply with the provisions of Chapter320, RSMo, which requires that outsidestairways be constructed of iron or steel. II

(16) Door locks shall be of a type that can beopened from the inside by turning the knob oroperating a simple device that will release thelock, or shall meet the requirements of Sec-tion 19.2 of NFPA 101, 2000 edition. Onlyone (1) lock will be permitted on any one (1)door. I/II

(17) All exit doors in existing licensed facili-ties shall be at least thirty inches (30") wide.II

(18) All exit doors in new facilities shall be atleast forty-four inches (44") wide. II

(19) In all facilities, all exit doors andvestibule doors shall swing outward in thedirection of exit travel. II

(20) In all existing licensed facilities, all hor-izontal exit doors in fire walls and all doorsin smoke barrier partitions may swing ineither direction. These doors normally maybe open, but shall be automatically self-clos-ing upon activation of the fire alarm system.They shall be capable of being manuallyreleased to self-closing action. II/III

(21) Facilities shall maintain corridors to befree of obstruction, equipment, or suppliesnot in use. Doors to resident rooms shall notswing into the corridor. II/III

(22) Facilities shall place signs bearing theword EXIT in plain, legible block letters ateach required exit, except at doors directlyfrom rooms to exit corridors or passageways.II

(23) Wherever necessary, the facility shallplace additional signs in corridors and pas-sageways to indicate the exit’s direction. Let-ters on these signs shall be at least six inches(6") high and principle strokes three-fourthsinch (3/4") wide, except that the letters ofinternally illuminated exit signs may be notless than four inches (4") high. III

(24) Facilities shall maintain all exit anddirectional signs to be clearly legible andelectrically illuminated at all times by accept-able means such as emergency lighting when

lighting fails. II

(25) Facilities shall have emergency lightingof sufficient intensity to provide for the safe-ty of residents and other people using anyexit, stairway, and corridor. The lighting shallbe supplied by an emergency service, anautomatic emergency generator or batterylighting system. This emergency lighting sys-tem shall be equipped with an automatictransfer switch. In an existing licensed facili-ty, battery lights, if used, shall be wet cellunits or other rechargeable-type batteries thatshall be UL-approved and capable of operat-ing the light for at least one and one-half (1½) hours. Battery-operated emergency light-ing shall be tested for at least thirty (30) sec-onds every thirty (30) days, and an annualfunction test shall be conducted for the fulloperational duration of one and one-half (1½) hours. Records of these tests shall bedocumented and maintained for review. II

(26) If existing licensed facilities have laun-dry chutes, dumbwaiter shafts, or other simi-lar vertical shafts, they shall have a fire resis-tance rating of at least one (1) hour if servingthree (3) or fewer stories. Enclosures servingfour (4) or more stories shall have at least atwo- (2-) hour fire-rated enclosure. Thesechute or shaft doors shall be self-closing orshall have any other approved device that willguarantee separation between floors. II

(27) Existing licensed multistoried facilitiesshall provide a smoke separation barrierbetween the basement and the first floor andthe floors of resident-use areas. At a mini-mum, this barrier shall consist of one-halfinch (1/2") gypsum board, plaster, or equiv-alent. There shall be a one and three-fourthsinch (1 3/4") thick solid-core wood door, orequivalent, at the top or bottom of the stairs.If the door is glazed, it shall be glazed withwired glass. II

(28) Each floor accessed by residents shall bedivided into at least two (2) smoke sectionswith each section not exceeding one hundredfifty feet (150') in length or width. If thefloor’s dimensions do not exceed seventy-fivefeet (75') in length or width, a division of thethe floor into two (2) smoke sections will notbe required. II

(29) Each smoke section shall be separated byone- (1-) hour fire-rated walls that are con-tinuous from outside wall-to-outside wall andfrom floor-to-floor or floor-to-roof deck. Alldoors in this wall shall be at least twenty-(20-) minute fire rated or its equivalent, self-closing, and may be held open only if the

door closes automatically upon activation ofthe fire alarm system. II

(30) Existing licensed facilities shall haveattached self-closing devices on all doors pro-viding separation between floors. If the doorsare to be held open, they shall have electro-magnetic hold-open devices that are intercon-nected with either a smoke alarm or withother smoke-sensitive fire extinguishment oralarm systems in the building. II/III

(31) Smoking shall be permitted only in des-ignated areas. Areas where smoking is per-mitted shall be directly supervised unless theresident has been assessed by the facility anddetermined capable of smoking unassisted.At least annually, the facility shall reassessthose residents the facility has determined tobe capable of smoking unsupervised and shallalso reassess such resident when changes inhis or her condition indicate the resident mayno longer be capable of smoking withoutsupervision. The facility shall document thisassessment in the resident’s medical record.II

(32) Designated smoking areas shall haveashtrays of noncombustible material and ofsafe design. The contents of ashtrays shall bedisposed of properly in receptacles made ofnoncombustible material. II/III

(33) Fire Drills and Emergency Preparedness.(A) All facilities shall have a written plan

to meet potential emergencies or disastersand shall request consultation and assistanceannually from a local fire unit for review offire and evacuation plans. If the consultationcannot be obtained, the facility shall informthe state fire marshal in writing and requestassistance in review of the plan. An up-to-date copy of the facility’s entire plan shall beprovided to the local jurisdiction’s emergencymanagement director. II/III

(B) The plan shall include, but is not lim-ited to—

1. A phased response ranging from relo-cation of residents to an immediate area with-in the facility; relocation to an area of refuge,if applicable; or to total building evacuation.This phased response part of the plan shall beconsistent with the direction of the local fireunit or state fire marshal and shall be appro-priate for the fire or emergency;

2. Written instructions for evacuation ofeach floor including evacuation to areas ofrefuge, if applicable, and floor plan showingthe location of exits, fire alarm pull stations,fire extinguishers, and any areas of refuge;


Secretary of State


3. Evacuating residents, if necessary,from an area of refuge to a point of safetyoutside the building;

4. The location of any additional watersources on the property such as cisterns,wells, lagoons, ponds, or creeks;

5. Procedures for the safety and comfortof residents evacuated;

6. Staffing assignments;7. Instructions for staff to call the fire

department or other outside emergency ser-vices;

8. Instructions for staff to call alterna-tive resource(s) for housing residents, if nec-essary;

9. Administrative staff responsibilities;and

10. Designation of a staff member to beresponsible for accounting for all residents’whereabouts. II/III

(C) The written plan shall be accessible atall times and an evacuation diagram shall beposted on each floor in a conspicuous placeso that employees and residents can becomefamiliar with the plan and routes to safety.II/III

(D) A minimum of twelve (12) fire drillsshall be conducted annually with at least one(1) every three (3) months on each shift. Atleast four (4) of the required fire drills mustbe unannounced to residents and staff,excluding staff who are assigned to evaluatestaff and resident response to the fire drill.The fire drills shall include a simulated resi-dent evacuation that involves the local firedepartment or emergency service at leastonce a year. II/III

(E) The fire alarm shall be activated duringall fire drills unless the drill is conductedbetween 9 p.m. and 6 a.m., when a facility-generated predetermined message is accept-able in lieu of the audible and visual compo-nents of the fire alarm. II/III

(F) The facility shall keep a record of allfire drills including the simulated residentevacuation. The record shall include the time,date, personnel participating, length of timeto complete the fire drill, and a narrativenotation of any special problems. III

(34) Fire Safety Training Requirements.(A) The facility shall ensure that fire safe-

ty training is provided to all employees: 1. During employee orientation; 2. At least every six (6) months; and3. When training needs are identified as

a result of fire drill evaluations. II/III(B) The training shall include, but is not

limited to, the following: 1. Prevention of fire ignition, detection

of fire, and control of fire development; 2. Confinement of the effects of fire;

3. Procedures for moving residents to anarea of refuge, if applicable;

4. Use of alarms;5. Transmission of alarms to the fire

department;6. Response to alarms;7. Isolation of fire;8. Evacuation of the immediate area and

building; 9. Preparation of floors and facility for

evacuation; and10. Use of the evacuation plan required

by section (33) of this rule. II/III

(35) The use of wood- or gas-burning fire-places will be permitted only if the fireplacesare built of firebrick or metal, enclosed bymasonry, and have metal or tempered glassscreens. The chimneys shall be of masonryconstruction with flue linings that have atleast eight inches (8") of masonry separatingthe flue lining and the fireplace from anycombustible material. All fireplaces shall beinstalled, operated, and maintained in a safemanner. Fireplaces not in compliance withthese requirements may be provided if theyare for decorative purposes only or if they areequipped with decorative-type electric logs orother electric heaters which bear the UL labeland are constructed of electrical componentscomplying with and installed in compliancewith the National Electrical Code, incorpo-rated by reference in this rule. Fireplacesmeeting standards set forth in NFPA 211,2000 edition, are considered in compliancewith this rule. II/III

(36) All electric or gas clothes dryers shall bevented to the outside and the lint trap cleanedregularly. II/III

(37) In existing licensed facilities, all walland ceiling surfaces shall be smooth and freeof highly-combustible materials. II/III

(38) All curtains in resident-use areas shall berendered and maintained flame-resistant inaccordance with NFPA 701, 1999 edition.II/III

(39) All new floor covering installed in build-ings that do not have a sprinkler system shallbe Class I in accordance with NFPA 253,2000 edition. II/III

(40) Trash and Rubbish Disposal Require-ments.

(A) Only metal or UL- or FM-approvedwastebaskets shall be used for the collectionof trash. II

(B) The facility shall maintain the exteriorpremises in a manner as to provide for firesafety. II

(C) Trash shall be removed from thepremises as often as necessary to prevent firehazards and public health nuisance. II

(D) No trash shall be burned within fiftyfeet (50') of any facility except in an approvedincinerator. I/II

(E) Trash may be burned only in a mason-ry or metal container. The container shall beequipped with a metal cover with openings nolarger than one-half inch (1/2") in size. II/III

(41) Minimum Staffing for Safety and Pro-tective Oversight to Residents.

(A) In a building that is of fire-resistantconstruction or a building with a sprinklersystem, minimum staffing shall be the fol-lowing:

Time Personnel Residents7 a.m. to 3 p.m. 1 3–10*(Day)

3 p.m. to 11 p.m. 1 3–15*(Evening)

11 p.m. to 7 a.m. 1 3–20*(Night)

*One (1) additional staff person for everyfraction after that. I/II

(B) In a building that is of nonfire-resistantconstruction or a building that has a sprinklersystem exemption, minimum staffing shall bethe following:

Time Personnel Residents7 a.m. to 3 p.m. 1 3–10*(Day)

3 p.m. to 11 p.m. 1 3–15*(Evening)

11 p.m. to 7 a.m. 1 3–15*(Night)

*One (1) additional staff person for everyfraction after that. I/II

AUTHORITY: sections 198.074 and 198.079,RSMo Supp. 2011.* This rule originally filedas 13 CSR 15-14.022. Original rule filed July13, 1983, effective Oct. 13, 1983. Amended:Filed Sept. 12, 1984, effective Dec. 13, 1984.Amended: Filed Aug. 1, 1988, effective Nov.11, 1988. Amended: Filed May 11, 1998,effective Dec. 30, 1998. Emergency amend-ment filed May 12, 1999, effective May 22,1999, expired Feb. 24, 2000. Amended: FiledJuly 13, 1999, effective Jan. 30, 2000. Movedto 19 CSR 30-85.022, effective Aug. 28, 2001.Emergency amendment filed Nov. 24, 2008,effective Dec. 4, 2008, expired June 1, 2009.Amended: Filed Nov. 24, 2008, effective May



30, 2009. Amended: Filed March 15, 2012,effective Oct. 30, 2012.

*Original authority: 198.074, RSMo 2007 and 198.079,RSMo 1979, amended 2007.

19 CSR 30-85.032 Physical Plant Require-ments for New and Existing IntermediateCare and Skilled Nursing Facilities

PURPOSE: This rule establishes the require-ments necessary in new and existing interme-diate care and skilled nursing facilities.

PUBLISHER’S NOTE: The secretary of statehas determined that the publication of theentire text of the material which is incorpo-rated by reference as a portion of this rulewould be unduly cumbersome or expensive.This material as incorporated by reference inthis rule shall be maintained by the agency atits headquarters and shall be made availableto the public for inspection and copying at nomore than the actual cost of reproduction.This note applies only to the reference mate-rial. The entire text of the rule is printedhere.

AGENCY NOTE: All rules relating to long-term care facilities licensed by the Division ofAging are followed by a Roman Numeralnotation which refers to the class (either classI, II or III) of standard as designated in sec-tion 198.085.1, RSMo.

(1) General Requirements.(A) All National Fire Protection Associa-

tion (NFPA) codes and standards cited in thisrule: NFPA 54, National Fuel Code, 1999edition; NFPA 58, Liquefied Petroleum GasCode, 1999 edition; NFPA 70, National Elec-tric Code, 1999 edition; NFPA 99, HealthCare Facilities, 1999 edition; and NFPA 101,The Life Safety Code, 2000 edition, areincorporated by reference in this rule andavailable for purchase from the National FireProtection Agency, 1 Batterymarch Park,Quincy, MA 02269-9101; www.nfpa.org; bytelephone at (617) 770-3000 or 1-800-344-3555. This rule does not incorporate any sub-sequent amendments or additions to the mate-rials listed above.

(B) This rule does not prohibit facilitiesfrom complying with standards set forth innewer editions of the incorporated by refer-ence material listed in subsection (1)(A) ofthis rule where approved by the Departmentof Health and Senior Services (the depart-ment).

(2) The building shall be substantially con-structed and shall be maintained in goodrepair. New facilities shall comply with the

requirements in accordance with the provi-sions found in 19 CSR 30-85.012. Existinglicensed facilities shall meet and maintain thefacility’s physical plant in accordance withthe construction standards in effect at thetime of initial licensing, unless there is a spe-cific rule governing the subject cited in thissection or in 19 CSR 30-85.022, except thatthose facilities licensed between 1957 and1965 shall not increase the capacity of anyroom or the total capacity of the facility with-out meeting new construction requirements.Existing licensed facilities with plansapproved after April 8, 1972 and prior to Jan-uary 1, 1999, shall comply as ExistingHealth Care Occupancies with NFPA 101,2000 edition. Facilities whose physical plantrequirement plans are approved on or afterJanuary 1, 1999, shall comply as New HealthCare Occupancies with NFPA 101, 2000 edi-tion. II/III

(3) In an existing facility licensed prior toJuly 1, 1965, the number of persons in anyroom or area used as sleeping quarters shallnot exceed the proportion of one (1) adult foreach sixty (60) square feet. In facilitieslicensed on or after July 1, 1965, adult resi-dent rooms shall be a minimum of eighty (80)square feet per bed in multi-bed residentrooms and one hundred (100) square feet forprivate rooms. This square footage caninclude all useable floor spaces such as clos-ets, entryways, and areas with moveableitems or furniture that do not impact the safe-ty or welfare of the resident, used for resi-dents’ belongings or if related to their care.Only the area of a room with a ceiling heightof at least seven feet (7') can be includedwhen calculating the square footage. II/III

(4) An existing facility licensed prior to July1, 1965 shall not use a private room less thansixty (60) square feet in size as sleeping quar-ters for residents under seventeen (17) yearsof age. In multi-bed resident rooms, the fol-lowing ratios shall apply: thirty (30) squarefeet per bed for beds four feet (4') or less inlength, forty (40) square feet per bed for bedsfour feet through five feet (4'–5') in lengthand sixty (60) square feet per bed for bedsover five feet (5') in length. In facilitieslicensed on or after July 1, 1965, rooms shallbe a minimum of thirty-five (35) square feetper bed for beds four feet (4') or less inlength; forty-five (45) square feet per bed forbeds four feet through five feet (4'–5') inlength; eighty (80) square feet per bed overfive (5) square feet in length in multiple bed-rooms; and one hundred (100) square feet forprivate rooms. II/III

(5) A facility may not house a resident in aroom which has an outside grade of more

than three feet (3') above the floor level onthe window side of the resident’s room for adistance of at least fifteen feet (15') from theoutside wall of the resident’s room. II/III

(6) Facilities initially licensed after July 1,1965 shall have no more than four (4) bedsper room. II/III

(7) The facility shall provide sleeping quar-ters, separate from resident bedrooms for theadministrator or employees and their familieswho reside there. III

(8) A facility shall conspicuously and unmis-takably identify each room or ward or resi-dent-use area with a number or room namesecurely fastened to, or plainly painted on theentrance of the room or ward. III

(9) Each resident room shall have an outsidewindow with an area equivalent to not lessthan ten percent (10%) of the required floorarea. The facility shall maintain windows sothat they may be readily opened and closed.II/III

(10) Facilities shall ensure that every windowin resident-use areas has shades, curtains ordrapes. III

(11) The facility shall make provisions for aroom(s) which can be used for isolation of aresident(s) with communicable diseases.Facilities licensed after July 1, 1965 andprior to June 11, 1981 shall have at least two(2) private rooms with a toilet room equippedwith toilet and handwashing sink. Rooms des-ignated as isolation rooms may be occupiedby residents provided there is a written agree-ment on file indicating the resident’s willing-ness to relocate without prior notice if theroom is needed for isolation purposes. III

(12) Every facility shall provide a living roomor community room for the sole use of resi-dents. Sufficient chairs and tables shall befurnished. Under no circumstances may theliving room be used as a bedroom. A livingroom must be well-lighted, ventilated, andeasily accessible to residents. II

(13) Facilities shall ensure that gas-burningequipment and appliances are approved bythe American Gas Association and installedin compliance with NFPA 54, 1999 edition.Where liquefied petroleum gas (LPG) isused, facilities shall comply with the rules ofthe Missouri Department of Agriculture andNFPA 58, 1999 edition. Facilities that werecomplying prior to the effective date of thisrule with prior editions of the NFPA 54 andNFPA 58 referenced in this rule shall be per-mitted to continue to comply with the earlier


Secretary of State




editions, as long as there is not an imminentdanger to the health, safety, or welfare of anyresident or a substantial probability that deathor serious physical harm would result asdetermined by department. Gas-fired waterheaters shall be properly vented and all waterheaters shall be equipped with a temperatureand pressure relief valve. II

(14) Oxygen cylinders for medical use shallbe labeled “Oxygen.” All facilities shall haveoxygen systems, oxygen piping, outlets, man-ifold rooms, and storage rooms installed inaccordance with the requirements of theNFPA 99, 1999 edition. I/II

(15) Facilities shall provide adequate storageareas for food, supplies, linen, equipmentand residents’ personal possessions. II/III

(16) Toilet rooms shall be easily accessible,conveniently located, well-lighted and prop-erly ventilated. Doors to toilet rooms whichmay be locked from the inside, shall beequipped with a special lock which may beopened from the outside. II/III

(17) Existing licensed facilities shall provideone (1) toilet for each ten (10) residents orfraction of ten. II/III

(18) The facility shall provide separate toiletfacilities for each sex. Where urinals are pro-vided for men, a facility shall provide one (1)toilet and urinal for each fifteen (15) males orfraction of fifteen. III

(19) Facilities shall provide grab bars on atleast one (1) side of all toilets, in proper posi-tions to facilitate bodily movement of resi-dents. II

(20) Existing licensed facilities shall providehandwashing facilities consisting of a hand-washing sink in each toilet room for each fif-teen (15) residents or fraction of fifteen. Thehandwashing sink may be omitted from a toi-let room which serves adjacent residentrooms if each room contains a handwashingsink. II/III

(21) The facility shall provide one (1) showeror tub for each fifteen (15) residents or frac-tion of fifteen. II/III

(22) Facilities shall have metal grab barssecurely mounted for bathtubs, shower stallsand toilets. The facility shall also providerubber or similar type nonskid mats or stripsin tubs and showers to reduce or prevent slip-ping accidents and hazardous conditions. II

(23) Facilities shall provide fixed partitions orcurtains in bathrooms and toilet areas toensure privacy. III

(24) The facility shall ensure that plumbingfixtures that supply hot water and are acces-sible to the residents, shall be thermostatical-ly controlled so the water temperature at thefixture does not exceed one hundred twentydegrees Fahrenheit (120°F) (49°C). Thewater shall be at a temperature range of onehundred five degrees Fahrenheit to onehundred twenty degrees Fahrenheit(105°F–120°F) (41°C–49°C). I/II

(25) Facilities shall provide adequate spaceand locations for the proper cleansing, disin-fection, sterilization, and storage of nursingsupplies and equipment. This area shall bespecifically designated as a clean utility area.There shall be a separate area designated as adirty utility area, and neither area shall belocated in or open into a kitchen, diningroom, or a bathroom. The facility shall haveutility areas that are easily available to per-sonnel and located conveniently for the nurs-ing station staff. Utility areas shall be well-ventilated and well-lighted. II/III

(26) The facility shall provide either a nurs-ing station or a nurses’ work area on eachfloor of a multistory facility. This area shallhave chart storage space on current residents.Facilities licensed or with plans approved onor after July 1, 1965, shall have a nurses’ sta-tion for every sixty (60) beds. Handwashingfacilities at or near the nurses’ station shall beavailable for physicians, nurses and other per-sonnel attending residents. II/III

(27) The facility shall be equipped with a callsystem that consists of an electrical intercom-munication system, a wireless pager system,a buzzer system, or hand bells for each resi-dent bed, toilet room, and bathroom. The callsystem shall be audible in the attendant’swork area and be in compliance with 19 CSR30-85.012(124). II/III

(28) The heating of the building shall berestricted to steam, hot water, permanentlyinstalled electric heating devices or warm airsystems employing either central heatingplants with installation so as to safeguard theinherent fire hazard or outside wall heaterswith approved installation. Portable heateruse is prohibited. Facilities shall provide ade-quate guards to safeguard residents wherepotential burn hazards exist. I/II

(29) The facility shall heat all resident-acces-sible areas to ensure that the air temperature

is not lower than sixty-eight degrees Fahren-heit (68°F). These areas shall be capable ofbeing heated to not less than eighty degreesFahrenheit (80°F). At all times the reason-able comfort needs of residents shall be met.I/II

(30) The facility shall cool resident-accessi-ble areas when air temperatures exceedeighty-five degrees Fahrenheit (85°F). Theseareas shall be capable of being cooled to atleast seventy-one degrees Fahrenheit (71°F).At all times the reasonable comfort needs ofresidents shall be met. I/II

(31) Electrical Wiring Requirements.(A) Electrical wiring and equipment shall

be installed and maintained in accordancewith the NFPA 70, 1999 edition. Facilitiesthat were complying prior to the effectivedate of this rule with prior editions of theNFPA 70 referenced in this rule shall be per-mitted to continue to comply with the earliereditions, as long as there is not an imminentdanger to the health, safety, or welfare of anyresident or a substantial probability that deathor serious physical harm would result asdetermined by the department. II/III

(B) Every two (2) years, a qualified elec-trician will be required to certify in writingthat the electrical system is being maintainedand operated in accordance with the stan-dards outlined by the NFPA 70, 1999 editionor the earlier NFPA 70 edition with which thefacility was complying prior to the effectivedate of this rule. II/III

(32) Lighting in hallways, bathrooms, recre-ational, dining, and all resident-use areasshall be provided with a minimum intensityof ten (10) footcandles and shall be sufficientto meet the residents’ and staff needs. III

(33) Facilities shall use night-lights in hall-ways, resident rooms, toilet rooms or bath-rooms and on stairways. II

(34) The facility shall ensure that a readinglight is provided for each resident whodesires to read. III

(35) To prevent direct glare to residents’ eyes,facilities shall ensure that lights in resident-use areas have a shade or dome. III

(36) If elevators are used, their installationand maintenance shall comply with all localand state codes and NFPA 70, 1999 edition.II

(37) If extension cords are used, they must beUnderwriters Laboratories (UL)-approved or

shall comply with other recognized electricalappliance approval standards and sized tocarry the current required for the applianceused. Only one (1) appliance shall be con-nected to one (1) extension cord. Only two(2) appliances may be served by one (1)duplex receptacle. Extension cords shall notbe placed under rugs, through doorways, orlocated where they are subject to physicaldamage. II/III

(38) The facility shall maintain furniture andequipment in good condition and shallreplace it if broken, torn, heavily soiled ordamaged. Rooms shall be designed and fur-nished so that the comfort and safety of theresidents are provided for at all times. II/III

(39) Rooms shall be neat, orderly andcleaned daily. II/III

(40) The facility shall ensure that each resi-dent shall be provided an individual bed, sin-gle or twin, in good repair of rigid type. Bedsshall be at least thirty-six inches (36") wide.Double beds of satisfactory construction maybe provided for married couples. Rollaway,metal cots or folding beds shall not be used.II/III

(41) A minimum of three feet (3') shall beavailable between parallel beds. III

(42) Mattresses shall be clean, in good repair,sized to fit the bed and a minimum of fourinches (4") in thickness to provide comfort.II/III

(43) The facility shall ensure that each bedhas at least one (1) clean comfortable pillow.Extra pillows shall be available to meet theneeds of the residents. III

(44) Multi-bed resident rooms shall havescreens or curtains, either portable or perma-nently affixed, available and used to provideprivacy as needed or as requested. III

(45) Facilities shall provide each residentwith an individual locker or other suitablespace for storage of clothing and personalbelongings. III

(46) The facility shall provide residents withan individual rack for towels and washclothsunless they are provided with clean wash-cloths or towels for use each time needed. III

(47) A comfortable chair shall be availablefor each resident’s use. III

(48) Only activities necessary to the adminis-tration of the facility shall be contained in any

building used as a long-term care facilityexcept as follows:

(A) Related activities may be conducted inbuildings subject to prior written approval ofthese activities by the department. Examplesof these activities are home health agencies,physician’s office, pharmacy, ambulance ser-vice, child day care, food service, and outpa-tient therapy for the elderly or disabled in thecommunity;

(B) Adult day care may be provided forfour (4) or fewer participants without priorwritten approval of the department if thelong-term care facility meets the followingstipulations:

1. The operation of the adult day carebusiness shall not interfere with the care anddelivery of services to the long-term care res-idents;

2. The facility shall only accept partici-pants in the adult day care program appropri-ate to the level of care of the facility andwhose needs can be met;

3. The facility shall not change the phys-ical layout of the facility without prior writtenapproval of the department;

4. The facility shall provide a privatearea for adult day care participants to nap orrest;

5. Adult day care participants shall notbe included in the census, and the numbershall not be more than four (4) above thelicensed capacity of the facility; and

6. The adult day care participants, whileon-site, are to be included in the determina-tion of staffing patterns for the long-term carefacility; and

(C) An associated adult day health careprogram may be operated without prior writ-ten approval if the provider of the adult dayhealth care services is certified in accordancewith 13 CSR 70-92.010. II/III

AUTHORITY: section 198.079, RSMo Supp.2007.* This rule originally filed as 13 CSR15-14.032. Original rule filed July 13, 1983,effective Oct. 13, 1983. Emergency amend-ment filed Nov. 9, 1983, effective Nov. 19,1983, expired March 18, 1984. Amended:Filed Nov. 9, 1983, effective Feb. 11, 1984.Amended: Filed Sept. 12, 1984, effectiveDec. 13, 1984. Amended: Filed Aug. 1,1988, effective Nov. 11, 1988. Amended:Filed May 11, 1998, effective Dec. 30, 1998.Emergency amendment filed Feb. 1, 1999,effective Feb. 11, 1999, expired Aug. 9, 1999.Amended: Filed Feb. 1, 1999, effective July30, 1999. Moved to 19 CSR 30-85.032, effec-tive Aug. 28, 2001. Amended: Filed March13, 2008, effective Oct. 30, 2008.

*Original authority: 198.079, RSMo 1979, amended 2007.

19 CSR 30-85.042 Administration and Res-ident Care Requirements for New andExisting Intermediate Care and SkilledNursing Facilities

PURPOSE: This rule establishes standardsfor administration and resident care in anintermediate care or skilled nursing facility.

Editor’s Note: All rules relating to long-termcare facilities licensed by the Division ofAging are followed by a Roman Numeralnotation which refers to the class (eitherClass I, II or III) of standard as designated insection 198.085.1, RSMo.

(1) The operator shall designate a person asadministrator who holds a current license asa nursing home administrator in Missouri. II

(2) The facility shall post the administrator’slicense. III

(3) The operator shall be responsible toassure compliance with all applicable lawsand rules. The administrator shall be fullyauthorized and empowered to make decisionsregarding the operation of the facility andshall be held responsible for the actions of allemployees. The administrator’s responsibili-ties shall include the oversight of residents toassure that they receive appropriate nursingand medical care. II/III

(4) The administrator shall be employed inthe facility and serve in that capacity on afull-time basis. An administrator cannot belisted or function as an administrator in morethan one (1) licensed facility at the sametime, except that one (1) administrator mayserve as the administrator of more than one(1) licensed facility if all facilities are on thesame premises. II/III

(5) The licensed administrator shall not leavethe premises without delegating the necessaryauthority in writing to a responsible individ-ual. If the administrator is absent from thefacility for more than thirty (30) consecutivedays, the person designated to be in adminis-trative charge shall be a currently licensednursing home administrator. Such thirty (30)consecutive-day absences may only occuronce within any consecutive twelve (12)-month period. I/II

(6) The facility shall not knowingly admit orcontinue to care for residents whose needscannot be met by the facility directly or incooperation with outside resources. Facilitieswhich retain residents needing skilled nursing


Secretary of State




care shall provide licensed nurses for theseprocedures. I/II

(7) When outside resources are used to pro-vide services to the resident, the facility shallenter into a written agreement with eachresource. III

(8) Persons under seventeen (17) years of ageshall not be admitted as residents to the facil-ity unless the facility cares primarily for res-idents under seventeen (17) years of age. III

(9) The facility shall not care for more resi-dents than the number for which the facilityis licensed. II

(10) The facility’s current license shall bereadily visible in a public area within thefacility. Notices provided to the facility by theDivision of Aging granting exceptions to reg-ulatory requirements shall be posted with thefacility’s license. III

(11) Regular daily visiting hours shall beestablished and posted. Relatives orguardians and clergy, if requested by the res-ident or family, shall be allowed to see criti-cally ill residents at any time unless the physi-cian orders otherwise in writing. II/III

(12) A supervising physician shall be avail-able to assist the facility in coordinating theoverall program of medical care offered in thefacility. II

(13) The facility shall develop policies andprocedures applicable to its operation toinsure the residents’ health and safety and tomeet the residents’ needs. At a minimum,there shall be policies covering personnelpractices, admission, discharge, payment,medical emergency treatment procedures,nursing practices, pharmaceutical services,social services, activities, dietary, housekeep-ing, infection control, disaster and accidentprevention, residents’ rights and handlingresidents’ property. II/III

(14) A pharmacist currently licensed in Mis-souri shall assist in the development of writ-ten policies and procedures regarding phar-maceutical services in the facility. II/III

(15) All personnel shall be fully informed ofthe policies of the facility and of their duties.II/III

(16) All persons who have any contact withthe residents in the facility shall not know-ingly act or omit any duty in a manner whichwould materially and adversely affect the

health, safety, welfare or property of a resi-dent. I

(17) Effective August 28, 1997, each facilityshall, not later than two (2) working days ofthe date an applicant for a position to havecontact with residents is hired, request acriminal background check, as provided insections 43.530, 43.540 and 610.120,RSMo. Each facility must maintain in itsrecord documents verifying that the back-ground checks were requested and the natureof the response received for each suchrequest. The facility must ensure that anyapplicant who discloses prior to the check ofhis/her criminal records that he/she has beenconvicted of, plead guilty or nolo contendereto, or has been found guilty of any A or Bfelony violation of Chapter 565, 566 or 569,RSMo, or any violation of subsection 3 ofsection 198.070, RSMo, or of section568.020, RSMo, will not be allowed to workin contact with patients or residents until andunless a check of the applicant’s criminalrecord shows that no such convictionoccurred. II/III

(18) The facility must develop and implementwritten policies and procedures which requirethat persons hired for any position which is tohave contact with any patient or resident havebeen informed of their responsibility to dis-close their prior criminal history to the facil-ity as required by section 660.317.5, RSMo.The facility—

(A) Shall also develop and implement poli-cies and procedures which ensure that thefacility does not knowingly hire, after August28, 1997, any person who has or may havecontact with a patient or resident, who hasbeen convicted of, plead guilty or nolo con-tendere to, in this state or any other state, orhas been found guilty of any A or B felonyviolation of Chapter 565, 566 or 569, RSMo,or any violation of subsection 3 of section198.070, RSMo, or of section 568.020,RSMo, unless the person has been granted agood cause waiver by the division;

(B) May consider for employment, in posi-tions which have contact with resident orpatients, any person who has been granted agood cause waiver by the division in accor-dance with the provisions of section 660.317,RSMo Supp. 1999 and 13 CSR 15-10.060;and;

(C) Shall contact the division to confirmthe validity of an applicant’s good causewaiver prior to hiring the applicant. II/III

(19) No person who is listed on the employ-ee disqualification list maintained by the divi-sion as required by section 198.070, RSMo

shall work or volunteer in the facility in anycapacity whether or not employed by theoperator. II

(20) The facility shall develop and offer anin-service orientation and continuing educa-tional program for the development andimprovement of skills of all the facility’s per-sonnel, appropriate for their job function.Facilities shall begin providing orientation onthe first day of employment for all personnelincluding licensed nurses and other profes-sionals. At a minimum, this shall cover pre-vention and control of infection, facility poli-cies and procedures including emergencyprotocol, job responsibilities and lines ofauthority, confidentiality of resident informa-tion and preservation of resident dignityincluding protection of the resident’s privacyand instruction regarding the property rightsof residents. Nursing assistants who have notsuccessfully completed the classroom portionof the state-approved training program priorto employment shall not provide direct resi-dent care until they have completed the six-teen (16)-hour, orientation module and atleast twelve (12) hours of supervised practi-cal orientation. This shall include, in addi-tion to the topics covered in the general ori-entation for all personnel, special focus onfacility protocols as well as practical instruc-tion on the care of the elderly and disabled.This orientation shall be supervised by alicensed nurse who is on duty in the facilityat the time orientation is provided. II/III

(21) Nursing assistants who have not success-fully completed the state-approved trainingprogram shall complete a comprehensive ori-entation program within sixty (60) days ofemployment. This may be part of a nursingassistant training program taught by anapproved instructor in the facility. It shallinclude, at a minimum, information on com-municable disease, handwashing and infec-tion control procedures, resident rights,emergency protocols, job responsibilities andlines of authority. II/III

(22) The facility must ensure there is a sys-tem of in-service training for nursing person-nel which identifies training needs related toproblems, needs, care of residents and infec-tion control and is sufficient to ensure staff’scontinuing competency. II/III

(23) Facilities shall conduct at least annualin-service education for nursing personnelincluding training in restorative nursing. Thistraining by a registered nurse or qualifiedtherapist shall include: turning and position-ing for the bedridden resident, range of

motion (ROM) exercises, ambulation assis-tance, transfer procedures, bowel and bladderretraining and self-care activities of daily liv-ing. II/III

(24) A registered nurse shall be responsiblefor the planning and then assuring the imple-mentation of the in-service education pro-gram for nursing personnel. II

(25) Facilities shall maintain records whichindicate the subject of, and attendance at, allin-service sessions. III

(26) All authorized personnel shall haveaccess to the legal name of each resident,name and telephone number of physician andnext of kin or responsible party of each resi-dent to contact in the event of emergency.II/III

(27) The facility must develop and imple-ment policies and procedures which ensureemployees are screened to identify communi-cable diseases and ensure that employeesdiagnosed with communicable diseases donot expose residents to such diseases. Thefacility’s policies and procedures must com-ply with the Missouri Department of Health’sregulations pertaining to communicable dis-eases, specifically 19 CSR 20-20.010 through19 CSR 20-20.100, as amended. II

(28) The administrator shall maintain on thepremises an individual personnel record oneach employee of the facility which shallinclude: the employee’s name and address;Social Security number; date of birth; date ofemployment; experience and education; ref-erences, if available; the result of backgroundchecks required by section 660.317, RSMo; acopy of any good cause waiver, granted by thedivision, if applicable; position in the facili-ty; record that the employee was instructedon resident’s rights; basic orientationreceived; and reason for termination, if appli-cable. Documentation shall be on file of alltraining received within the facility in addi-tion to current copies of licenses, transcripts,certificates or statements evidencing compe-tency for the position held. Facilities shallretain personnel records for at least one (1)year following termination of employment.III

(29) Facilities shall maintain written docu-mentation on the premises showing actualhours worked by each employee. III

(30) All persons who have or may have con-tact with residents shall at all times when onduty or delivering services wear an identifi-

cation badge. The badge shall give theirname, title and, if applicable the status oftheir license or certification as any kind ofhealth care professional. This rule shall applyto all personnel who provide services to anyresident directly or indirectly. III

(31) Employees other than nursing personnelshall be at least sixteen (16) years of age.II/III

(32) Nursing personnel shall be at least eigh-teen (18) years of age except that a personbetween the ages of seventeen (17) years ofage and eighteen (18) years of age may pro-vide direct resident care if he/she has suc-cessfully completed the state-approved nurs-ing assistant course and has been certifiedwith his/her name on the state nursing assis-tant register. He/she must work under thedirect supervision of a licensed nurse and willnever be left responsible for a nursing unit.II/III

(33) All nurses employed by the facility shallbe currently licensed in Missouri. II

(34) All facilities shall employ a director ofnursing on a full-time basis who shall beresponsible for the quality of patient care andsupervision of personnel rendering patientcare. II

(35) Licensed Nursing Requirements; SkilledNursing Facility.

(A) The director of nursing shall be a reg-istered nurse. II

(B) A registered nurse shall be on duty inthe facility on the day shift. Either a licensedpractical nurse (LPN) or a registered profes-sional nurse (RN) shall be on duty in thefacility on both the evening and night shifts.II

(C) A registered nurse shall be on call dur-ing the time when only an LPN is on duty. II

(36) Licensed Nursing Requirements; Inter-mediate Care Facilities.

(A) The director of nursing shall be eitheran RN or an LPN. II

(B) When the director of nursing is anLPN, an RN shall be employed as consultanta minimum of four (4) hours per week to pro-vide consultation to the administrator and thedirector of nursing in matters relating to nurs-ing care in the facility. II

(C) An LPN or RN shall be on duty and inthe facility on the day shift. II

(D) An LPN or RN shall be on call twen-ty-four (24) hours a day, seven (7) days aweek. I/II

(37) All facilities shall employ nursing per-sonnel in sufficient numbers and with suffi-cient qualifications to provide nursing andrelated services which enable each resident toattain or maintain the highest practicablelevel of physical, mental and psychosocialwell-being. Each facility shall have alicensed nurse in charge who is responsiblefor evaluating the needs of the residents on adaily and continuous basis to ensure there aresufficient, trained staff present to meet thoseneeds. I/II

(38) Nursing personnel shall be on duty at alltimes on each resident-occupied floor. II

(39) Nursing assistants employed after Jan-uary 1, 1980, shall have completed mandato-ry training as required by section 198.082,RSMo, or be enrolled in the course and func-tioning under the supervision of a stateapproved instructor of clinical supervisor aspart of the one hundred (100) hours of on-the-job training. The person enrolled shall havesuccessfully completed the course andbecome certified within one (1) year ofemployment with a licensed-only facility orwithin four (4) months of employment with afacility certified under Title XVIII or TitleXIX if he or she is to remain employed in thefacility as a nursing assistant. II

(40) Nursing personnel in any facility withmore than twenty (20) residents shall not rou-tinely perform non-nursing duties. II/III

(41) Nursing personnel in facilities withtwenty (20) residents or less shall performnon-nursing duties only if acceptable infec-tion control measures are maintained. II/III

(42) Each facility resident shall be under themedical supervision of a Missouri-licensedphysician who has been informed of the facil-ity’s emergency medical procedures and iskept informed of treatments or medicationsprescribed by any other professional lawfullyauthorized to prescribe medications. I/II

(43) Facilities shall ensure that at the timethe resident is admitted, the facility obtainsfrom a physician the resident’s primary diag-nosis along with current medical findings andthe written orders for the immediate care ofthe resident. II/III

(44) The facility shall ensure that the resi-dent’s private physician, the physician’sdesignee, the facility’s supervising physicianor an alternate physician shall examine theresident at least annually, and shall examine


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the resident as often as necessary to ensureproper medical care. I/II

(45) For each medical examination, thephysician must review the resident’s care,including medications and treatments; write,sign and date progress notes; and sign anddate all orders. The facility shall establish apolicy requiring the physician to sign ordersand to complete all other documentationrequired if the physician does not visit theresident routinely. II/III

(46) No medication, treatment or diet shallbe given without a written order from a per-son lawfully authorized to prescribe such andthe order shall be followed. No restraint shallbe applied except as provided in 13 CSR 15-18.010, Resident Rights. I/II

(47) There shall be a safe and effective sys-tem of medication distribution, administra-tion, control and use. I/II

(48) Verbal and telephone orders for medi-cation or treatment shall be given only tothose individuals licensed or certified toaccept orders. Orders shall be immediatelyreduced to writing and signed by that indi-vidual. If a telephone order is given to a cer-tified medication technician, an initial dose ofmedication or treatment shall not be givenuntil the order has been reviewed by tele-phone or in person by a licensed nurse orpharmacist. The review shall be documentedby the reviewer co-signing the telephoneorder. II

(49) Medications shall be administered onlyby a licensed physician, a licensed nurse or amedication technician who has successfullycompleted the state-approved course for med-ication administration. II

(50) Injectable medication, other thaninsulin, shall be administered only by alicensed physician or a licensed nurse.Insulin injections may be administered by acertified medication technician who has suc-cessfully completed the state-approved coursefor insulin administration. II

(51) Self-administration of medication is per-mitted only if approved in writing by the res-ident’s physician and it is in accordance withthe facility’s policy and procedures. II

(52) All medication errors and adverse reac-tions shall be reported immediately to thenursing supervisor and the resident’s physi-cian and, if there was a dispensing error, tothe issuing pharmacist. II/III

(53) At least monthly a pharmacist or a reg-istered nurse shall review the drug regimen ofeach resident. Irregularities shall be report-ed in writing to the resident’s physician, theadministrator and the director of nurses.There must be written documentation whichindicates how the reports were acted upon.II/III

(54) All prescription medications shall besupplied as individual prescriptions. Allmedications, including over-the-counter med-ications, shall be packaged and labeled inaccordance with applicable professionalpharmacy standards and state and federaldrug laws and regulations. The United StatesPharmacopoeia (USP) labeling shall includeaccessory and cautionary instructions as wellas the expiration date, when applicable, andthe name of the medication as specified in thephysician’s order. Over-the-counter medica-tions for individual residents shall be labeledwith at least the resident’s name. II/III

(55) If the resident brings medications to thefacility, they shall not be used unless the con-tents have been examined, identified and doc-umented by a pharmacist or a physician.II/III

(56) Facilities shall store all external andinternal medications at appropriate tempera-tures in a safe, clean place and in an orderlymanner apart from foodstuffs and dangerouschemicals. A facility shall secure all medica-tions, including those refrigerated, behind atleast one (1) locked door or cabinet. Facili-ties shall store containers of discontinuedmedication separately from current medica-tions. II/III

(57) Facilities shall store Schedule II medica-tions, including those in the emergency drugsupply, under double lock separately fromnoncontrolled medication. Schedule II med-ications may be stored and handled with othernoncontrolled medication if the facility has asingle unit dose drug distribution system inwhich the quantity stored is minimal and amissing dose can be readily detected. II

(58) Upon discharge or transfer, a residentmay be given medications with a writtenorder from the physician. Instructions for theuse of those medications will be provided tothe resident or the resident’s designee. III

(59) All non-unit doses and all controlledsubstances which have been discontinuedmust be destroyed on the premises withinthirty (30) days. Outdated, contaminated ordeteriorated medications and non-unit dose

medications of deceased residents shall bedestroyed within thirty (30) days. Unit dosemedications returnable to the pharmacy shallbe returned within thirty (30) days. II/III

(60) Medications shall be destroyed in thefacility by a pharmacist and a licensed nurseor by two (2) licensed nurses. III

(61) Facilities shall maintain records of med-ication destroyed in the facility. Recordsshall include: the resident’s name; the date;the name, strength and quantity of the medi-cation; the prescription number; and the sig-natures of the participating parties. III

(62) The facility shall maintain records ofmedication released to the family or residentupon discharge or to the pharmacy. Recordsshall include: the resident’s name; the date;the name, strength and quantity of the medi-cation; the prescription number; and the sig-nature of the persons releasing and receivingthe medication. III

(63) The facility must establish a system ofrecords of receipt and disposition of all con-trolled drugs in sufficient detail to enable anaccurate reconciliation. The system mustenable the facility to determine that drugrecords are in order and that an account of allcontrolled drugs is maintained and recon-ciled. II/III

(64) Facilities shall make available to allnursing staff up-to-date reference material onall medications in use in the facility. III

(65) The facility shall develop policies toidentify any emergency stock supply of pre-scription medications to be kept in the facili-ty for resident use only. This emergency drugsupply must be checked at least monthly by apharmacist to ensure its safety for use andcompliance with facility policy. A facilityshall have the emergency drug supply readilyavailable to medical personnel and use ofmedications in the emergency drug supplyshall assure accountability. III

(66) Each resident shall receive twenty-four(24)-hour protective oversight and supervi-sion. For residents departing the premises onvoluntary leave, the facility shall have, at aminimum, a procedure to inquire of the resi-dent or resident’s guardian of the resident’sdeparture, of the resident’s estimated lengthof absence from the facility, and of the resi-dent’s whereabouts while on voluntary leave.I/II


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(67) Each resident shall receive personalattention and nursing care in accordance withhis/her condition and consistent with currentacceptable nursing practice. I/II

(68) Each resident shall be clean, dry andfree of body and mouth odor that is offensiveto others. I/II

(69) Taking into consideration the resident’spreferences, residents shall be well-groomedand dressed appropriately for the time of day,the environment and any identified medicalconditions. II/III

(70) Residents who are physically or mental-ly incapable, or both, of changing their ownpositions shall have their positions changed atleast every two (2) hours and shall be provid-ed supportive devices to maintain good bodyalignment. I/II

(71) The facility must provide each residentthe opportunity to access sufficient fluids tomaintain proper hydration in accordance withthe resident’s medical condition and goals oftreatment as documented in the medicalrecord. I/II

(72) All residents who require assistance atmealtimes, whether it be preparation of thefood items or actual feeding, shall be provid-ed the assistance upon delivery of the tray.Facilities shall provide dining room supervi-sion during meals. II/III

(73) Facilities shall provide each resident,according to his/her needs, with restorativenursing to encourage independence, activityand self-help to maintain strength and mobil-ity. Each resident shall be out of bed asdesired unless medically contraindicated. II

(74) Each resident shall have skin careincluding the application of oil, lotion andcream as needed to prevent dryness and scal-ing of skin. II/III

(75) Facilities shall keep residents free fromavoidable pressure sores, taking measurestoward prevention. If sores exist, staff shallgive adequate treatment. I/II

(76) Facility staff shall check residentsrequiring restraints every thirty (30) minutesand exercise the residents every two (2)hours. II/III

(77) Facilities shall not use locked restraints.I

(78) Residents shall be cared for by usingacceptable infection control procedures toprevent the spread of infection. The facilityshall make a report to the division withinseven (7) days if a resident is diagnosed ashaving a communicable disease, as deter-mined by the Missouri Department of Healthand listed in the Code of State Regulationspertaining to communicable diseases, specif-ically 19 CSR 20-20.020, as amended. I/II

(79) In the event of accident, injury or sig-nificant change in the resident’s condition,facility staff shall notify the resident’s physi-cian in accordance with the facility’s emer-gency treatment policies which have beenapproved by the supervising physician. I/II

(80) In the event of accident, injury or sig-nificant change in the resident’s conditions,facility staff shall immediately notify the per-son designated in the resident’s record as thedesignee or responsible party. III

(81) Staff shall inform the administrator ofaccidents, injuries and unusual occurrenceswhich adversely affect, or could adverselyaffect, the resident. The facility shall devel-op and implement responsive plans of action.III

(82) Facilities shall ensure that each residentis provided individual personal care itemsnecessary for good grooming. Items shall bestored and maintained in a clean mannerwithin the resident’s room. III

(83) Facilities shall provide equipment andnursing supplies in sufficient number to meetthe needs of the residents. II/III

(84) Facilities shall keep all utensils andequipment in good condition, effectively san-itized, sterilized, or both, and stored to pre-vent contamination. II/III

(85) Staff shall ensure that bedpans, com-modes and urinals are covered after use,emptied promptly and thoroughly cleanedafter use. II/III

(86) Facilities shall provide and use a suffi-cient supply of clean bed linen, includingsheets, pillow cases, blankets and mattresspads to assure that resident beds are keptclean, neat, dry and odor free. II/III

(87) Staff shall use moisture proof covers asnecessary to keep mattresses and pillowsclean, dry and odor free. II/III

(88) Facilities shall provide each residentwith fresh bath towels, hand towels and wash-cloths as needed for individual usage. II/III

(89) In addition to rehabilitative or restora-tive nursing, all facilities shall provide ormake arrangements for providing rehabilita-tion services to all residents according totheir needs. If a resident needs rehabilitationservices, a qualified therapist shall performan evaluation on written order of the resi-dent’s physician. II/III

(90) Facilities shall ensure that rehabilitationservices are provided by or under the on-sitesupervision of a qualified therapist or a qual-ified therapy assistant who works under thegeneral supervision of a qualified therapist.I/II

(91) Staff shall include the following in doc-umentation of rehabilitation services: physi-cian’s written approval for proposed plan ofcare; progress notes at least every thirty (30)days by the therapist; daily record of the pro-cedure(s) performed; summary of therapywhen rehabilitation has been reached and, ifapplicable, recommendations for mainte-nance procedures by restorative nursing. III

(92) The facility shall designate a staff mem-ber to be responsible for the facility’s socialservices program. The designated staff per-son shall be capable of identifying social andemotional needs, knowledgeable of methodsor resources, or a combination of these, touse to meet them and services shall be pro-vided to residents as needed. II/III

(93) The facility shall designate an employ-ee to be responsible for the activity program.The designated person shall be capable ofidentifying activity needs of residents,designing and implementing programs tomaintain or increase, or both, the resident’scapability in activities of daily living. Facil-ities shall provide activity programs on a reg-ular basis. Each resident shall have a plannedactivity program which includes individual-ized activities, group activities and activitiesoutside the facility as appropriate to his/herneeds and interests. II/III

(94) The facility shall provide and use ade-quate space and equipment within the facilityfor the identified activity needs of residents.II/III

(95) The facility shall establish and maintaina program for informing all residents inadvance of available activities, activity loca-tion and time. III



(96) Facility staff shall include the followinggeneral information in admission records:resident’s name; prior address; age (birthdate); sex; marital status; Social Securitynumber; Medicare and Medicaid numbers;date of admission; name, address and tele-phone number of responsible party; name,address and telephone number of attendingphysician; height and weight on admission;inventory of resident’s personal possessionsupon admission; and names of preferred den-tist, pharmacist and funeral director. II/III

(97) Facility staff shall include physicianentries in the medical record with the follow-ing information: admission diagnosis, admis-sion physical and findings of subsequentexaminations; progress notes; orders for allmedications and treatment; orders for extentof activity; orders for restraints includingtype and reason for restraint; orders for diet;and discharge diagnosis or cause of death.II/III

(98) Residents admitted to a facility on refer-ral by the Department of Mental Health shallhave an individualized treatment plan or indi-vidualized habilitation plan on file which isupdated annually. III

(99) Facilities shall ensure that the clinicalrecord contains sufficient information to—

(A) Identify the resident;(B) Reflect the initial and ongoing assess-

ments and interventions by each disciplineinvolved in the care and treatment of the res-ident; and

(C) Identify the discharge or transfer desti-nation. II/III

(100) Facilities shall ensure that the resident’sclinical record must contain progress notesthat include, but are not limited to:

(A) Response to care and treatment;(B) Change(s) in physical, mental and psy-

chosocial condition;(C) Reasons for changes in treatment; and(D) Reasons for transfer or discharge.

II/III

(101) The facility must safeguard clinicalrecord information against loss, destructionor unauthorized use. III

(102) The facility must keep all informationconfidential that is contained in the resident’srecords regardless of the form or storagemethod of the records, including video-,audio- or computer-stored information. III

(103) The facility must maintain clinicalrecords on each resident in accordance with

accepted professional standards and prac-tices. These records shall be complete, accu-rately documented, readily accessible oneach nursing unit and systematically orga-nized. II/III

(104) Facilities must retain clinical recordsfor the period of time required by state law orfive (5) years from the date of discharge whenthere is no requirement in state law. III

(105) Facilities shall retain all financialrecords related to the facility operation forseven (7) years from the end of the facility’sfiscal year. III

(106) In the event the resident is transferredfrom the facility, the resident shall be accom-panied by a copy of the medical history,transfer forms which include the physicalexam report, nursing summary and report oforders physicians prescribed. II/III

AUTHORITY: sections 198.006, RSMo Supp.2003 and 198.079, RSMo 2000.* This ruleoriginally filed as 13 CSR 15-14.042. Origi-nal rule filed July 13, 1983, effective Oct. 13,1983. Emergency amendment filed Nov. 9,1983, effective Nov. 19, 1983, expired March18, 1984. Amended: Filed Nov. 9, 1983,effective Feb. 11, 1984. Amended: Filed Sept.12, 1984, effective Dec. 13, 1984. Amended:Filed Aug. 1, 1988, effective Nov. 10, 1988.Amended: Filed Jan. 3, 1992, effective Aug.6, 1992. Amended: Feb. 13, 1998, effectiveSept. 30, 1998. Amended: Filed Feb. 15,2000, effective Aug. 30, 2000. Moved to 19CSR 30-85.042, effective Aug. 28, 2001.Emergency amendment filed Sept. 12, 2003,effective Sept. 22, 2003, expired March 19,2004. Amended: Filed Sept. 12, 2003, effec-tive Feb. 29, 2004.

*Original authority: 198.006, RSMo 1979, amended1984, 1987, 2003; 198.079, RSMo 1979.

19 CSR 30-85.052 Dietary Requirementsfor New and Existing Intermediate Careand Skilled Nursing Facilities

PURPOSE: This rule establishes dietaryrequirements for new and existing intermedi-ate care and skilled nursing facilities.

Editor’s Note: All rules relating to long-termcare facilities licensed by the Division ofAging are followed by a Roman Numeralnotation which refers to the class (eitherClass I, II or III) of standard as designated insection 198.085.1, RSMo.

(1) Each resident shall be served nutritiousfood, properly prepared and appropriatelyseasoned, taking into consideration residentfood preferences, to provide an adequate dietin accordance with the physician’s order andas recommended by the National ResearchCouncil. Nutritional needs of residents shallbe met and shall be based on the individual’scircumstances, medical condition and goalsof treatment as determined and justified bythe physician. A qualified professional, suchas a dietitian or registered nurse, shall regu-larly assess these needs and shall keep thephysician informed of the nutritional status ofthe resident. I/II

(2) At least three (3) substantial meals orother equivalent shall be served daily at reg-ular hours with supplementary feedings asnecessary. At least two (2) meals shall behot.II/III

(3) Foods shall be prepared and served usingmethods that conserve nutritive value, flavorand appearance. II/III

(4) Special attention shall be given to the tex-ture of food given to residents who havechewing difficulty. II/III

(5) Provision shall be made to assure that hotfood is served hot and cold food is servedcold. II

(6) If a resident refuses food served, appro-priate substitutes of similar nutritive valueshall be offered. II/III

(7) Bedtime snacks of nourishing quality shallbe offered to all residents unless medicallycontraindicated. III

(8) Tray service and dining room service forresidents shall be attractive and each residentshall receive appropriate table service. III

(9) Each resident who is served meals in bedor in a chair not within the dining area shallbe provided with either a table, an overbedtable or an overbed tray of sturdy construc-tion which is positioned so that the residentcan eat comfortably. III

(10) A time schedule for service of meals toresidents shall be established. Meals shall beserved approximately four to five (4–5) hoursapart and not longer than fourteen (14) hoursfrom a substantial evening meal to breakfast.II/III

(11) A minimum of thirty (30) minutes shallbe given for eating meals. Residents who eat


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slowly or who need assistance shall be givenas much time to eat as necessary. II/III

(12) An identification system shall be estab-lished to assure that each resident receives thediet as ordered. II/III

(13) If the residents have objectionable tablemanners, an alternate method of meal serviceshall be provided. III

(14) There shall be sufficient personnel prop-erly trained in their duties to assure adequatepreparation and serving of food. II

(15) All facilities shall employ a food servicesupervisor who shall have overall superviso-ry responsibility for dietary services. II

(16) Menus for special prescribed diets shallbe reviewed and approved in writing by eithera qualified dietitian, a registered nurse or aphysician. II/III

(17) If food preparation, service, or both,within the facility is handled through a con-tractual arrangement, all regulations govern-ing sanitation (13 CSR 15-17), dietary ser-vice and contractual personnel shall be metand maintained. II/III

(18) If it is determined by the Division ofAging that due to the complexity of pre-scribed diets or that the food service supervi-sor is unable to assure compliance with thedietary requirements, the facility shall berequired to employ, for specified periods oftime, a qualified dietitian to serve as a con-sultant and until the food service managementimproves to assure that the residents’ needsare being met. II

(19) A current record of purchased food shallbe kept to show the kind and amount of foodpurchased each month. III

(20) Supplies of staple food for a minimum ofa one (1)-week period and of perishable foodsfor a minimum of a three (3)-day period shallbe maintained on the premises. II

(21) Menus for all diets shall be planned atleast two (2) weeks in advance. If cyclemenus are used, the cycle must cover a mini-mum of three (3) weeks and must be differ-ent each day of the week. Menus showing thefoods and amounts of food to be served eachday during the current week shall be postedwhere seen readily as food is prepared andserved. Each day’s menu shall show the dateit was actually used and shall be kept on file

for thirty (30) days. A list of substitutionsshall be kept for thirty (30) days. III

(22) A file of standardized recipes shall beused. III

(23) A diet manual approved by the Divisionof Aging shall be readily available to attend-ing physicians, nursing and dietary person-nel. III

AUTHORITY: section 198.009, RSMo 1986.*This rule originally filed as 13 CSR 15-14.052. Original rule filed July 13, 1983,effective Oct. 13, 1983. Amended: Filed Aug.1, 1988, effective Nov. 10, 1988. Amended:Filed Jan. 3, 1992, effective Aug. 6, 1992.Moved to 19 CSR 30-85.052, effective Aug.28, 2001.

*Original authority: 198.009, RSMo 1979.

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