PURPOSE: This rule establishes the requirements necessary in new and existing intermediate care and skilled nursing facilities.

PUBLISHER’S NOTE: The publication of the full text of the material that the adopting agency has incorporated by reference in this rule would be unduly cumbersome or expensive. Therefore, the full text of that material will be made available to any interested person at both the Office of the Secretary of State and the office of the adopting agency, pursuant to section 536.031.4, RSMo. Such material will be provided at the cost established by state law. Editor’s Note: All rules relating to long-term care facilities licensed by the Division of Aging are followed by a Roman Numeral notation which refers to the class (either class I, II or III) of standard as designated in section 198.085.1, RSMo.

1. (1) The building shall be substantially constructed and shall be maintained in good repair. New facilities shall comply with the requirements in accordance with the provisions found in 13 CSR 15-14.012. When a new facility or an addition to an existing facility is licensed, no different construction requirements shall be imposed on the operator, provided the facility is being maintained in good repair as originally approved for licensure, providing the health, safety and welfare of the residents is not in jeopardy. Existing licensed facilities shall meet and maintain the facility’s physical plant in accordance with the construction standards in effect at the time of initial licensing, unless there is a specific rule governing the subject cited in this section or in 13 CSR 15-14.022, except that those facilities licensed between 1957 and 1965 shall not increase the capacity of any room or the total capacity of the facility without meeting new construction requirements. Existing licensed facilities with plans approved after April 8, 1972 and prior to January 1, 1999, shall comply as existing facilities with the 1985 Life Safety Code (National Fire Protection Association NFPA 101), which is incorporated by reference in this rule, except that no provision of the 1985 code will be enforced that is more restrictive than the code of original plan approval. New facilities whose physical plant requirement plans are approved on or after January 1, 1999, shall comply with the provisions of the 1997 Life Safety Code, incorporated by reference in this rule. II/III
2. (2) Only activities necessary to the administration of the facility shall be contained in any building used as a long-term care facility except that related activities may be conducted in buildings subject to the division’s prior written approval. Examples of activities are home health agencies, physician’s office, pharmacy, ambulance service, day care and food service for the elderly in the community. II/III
3. (3) In an existing facility licensed prior to July 1, 1965, the number of persons in any room or area used as sleeping quarters shall not exceed the proportion of one (1) adult for each sixty (60) square feet. In facilities licensed on or after July 1, 1965, adult resident rooms shall be a minimum of eighty (80) square feet per bed in multi-bed resident rooms and one hundred (100) square feet for private rooms. This square footage can include all useable floor spaces such as closets, entryways, built-in furniture and equipment if used for residents’ belongings or if related to their care. Only the area of a room with a ceiling height of at least seven feet (7') can be included when calculating the square footage. II/III
4. (4) An existing facility licensed prior to July 1, 1965 shall not use a private room less than sixty (60) square feet in size as sleeping quarters for residents under seventeen (17) years of age. In multi-bed resident rooms, the following ratios shall apply: thirty (30) square feet per bed for beds four feet (4') or less in length, forty (40) square feet per bed for beds four feet through five feet (4'–5') in length and sixty (60) square feet per bed for beds over five feet (5') in length. In facilities licensed on or after July 1, 1965, rooms shall be a minimum of thirty-five (35) square feet per bed for beds four feet (4') or less in length; forty-five (45) square feet per bed for beds four feet through five feet (4'–5') in length; eighty (80) square feet per bed over five (5) square feet in length in multiple bedrooms; and one hundred (100) square feet for private rooms. II/III
5. (5) A facility may not house resident in a room which has an outside grade of more than three feet (3') above the floor level on the window side of the resident’s room for a distance of at least fifteen feet (15') from the outside wall of the resident’s room. II/III
6. (6) Facilities initially licensed after July 1, 1965 shall have no more than four (4) beds per room. II/III
7. (7) The facility shall provide sleeping quarters, separate from resident bedrooms for the administrator or employees and their families who reside there. III
8. (8) A facility shall conspicuously and unmistakably identify each room or ward or resident-use area with a number or room name securely fastened to, or plainly painted on the entrance of the room or ward. III
9. (9) Each resident room shall have an outside window with an area equivalent to not less than ten percent (10%) of the required floor area. The facility shall maintain windows so that they may be readily opened and closed. II/III
10. (10) Facilities shall ensure that every window in resident-use areas has shades, curtains or drapes. III
11. (11) The facility shall make provisions for a room(s) which can be used for isolation of a resident(s) with communicable diseases. Facilities licensed after July 1, 1965 and prior to June 11, 1981 shall have at least two
12. (2) private rooms with a toilet room equipped with toilet and handwashing sink. Rooms designated as isolation rooms may be occupied by residents provided there is a written agreement on file indicating the resident’s willingness to relocate without prior notice if the room is needed for isolation purposes. III
13. (12) Every facility shall provide a living room or community room for the sole use of residents. Sufficient chairs and tables will be furnished. Under no circumstances may the living room be used as a bedroom. A living room must be well-lighted, ventilated and easily accessible to residents. II
14. (13) Facilities shall ensure that gas-burning equipment and appliances are approved by the American Gas Association and installed in compliance with the 1996 NFPA 54, National Fuel Gas Code, incorporated by reference in this rule. Where liquefied petroleum gas (LPG) is used, facilities shall comply with the rules of the Missouri Department of Agriculture and the 1995 13 CSR 15-14

NFPA 58, Storage and Handling of Liquefied Petroleum Gases, incorporated by reference in this rule. Facilities with gas-burning equipment installed on or before December 31, 1998, shall comply with instructions and requirements of the NFPA 54 and NFPA 58 referenced in the 1985 Life Safety Code. Gas-fired water heaters shall be properly vented and all water heaters shall be equipped with a temperature and pressure relief valve. II

1. (14) Oxygen cylinders for medical use shall be labeled Oxygen—United States Pharmacopoeia (USP). Existing facilities with plans approved on or before December 31, 1998, shall have oxygen systems, oxygen piping, outlets, manifold rooms and storage rooms installed in accordance with the requirements of the NFPA 99, Health Care Facilities, as referenced in the 1985 Life Safety Code. Facilities with plans approved on or after January 1, 1999, shall install oxygen systems in compliance with the 1996 NFPA 99 and the 1997 Life Safety Code. I/II
2. (15) Facilities shall provide adequate storage areas for food, supplies, linen, equipment and residents’ personal possessions. II/III
3. (16) Toilet rooms shall be easily accessible, conveniently located, well-lighted and properly ventilated. Doors to toilet rooms which may be locked from the inside, shall be equipped with a special lock which may be opened from the outside. II/III
4. (17) Existing licensed facilities shall provide one (1) toilet for each ten (10) residents or fraction of ten. II/III
5. (18) The facility shall provide separate toilet facilities for each sex. Where urinals are provided for men, a facility shall provide one (1) toilet and urinal for each fifteen (15) males or fraction of fifteen. III
6. (19) Facilities shall provide grab bars on at least one (1) side of all toilets, in proper positions to facilitate bodily movement of residents. II
7. (20) Existing licensed facilities shall provide handwashing facilities consisting of a handwashing sink in each toilet room for each fifteen (15) residents or fraction of fifteen. The handwashing sink may be omitted from a toilet room which serves adjacent resident rooms if each room contains a handwashing sink. II/III
8. (21) The facility shall provide one (1) shower or tub for each fifteen (15) residents or fraction of fifteen. II/III
9. (22) Facilities shall have metal grab bars securely mounted for bathtubs, shower stalls and toilets. The facility shall also provide rubber or similar type nonskid mats or strips in tubs and showers to reduce or prevent slipping accidents and hazardous conditions. II
10. (23) Facilities shall provide fixed partitions or curtains in bathrooms and toilet areas to ensure privacy. III
11. (24) The facility shall ensure that plumbing fixtures that supply hot water and are accessible to the residents, shall be thermostatically controlled so the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit (120°F) (49°C). The water shall be at a temperature range of one hundred five degrees Fahrenheit to one hundred twenty degrees Fahrenheit (105°F–120°F) (41°C–49°C). I/II
12. (25) Facilities shall provide adequate space and locations for the proper cleansing, disinfection, sterilization and storage of nursing supplies and equipment. This area shall be specifically designated as a clean utility area. There shall be a separate area designated as a dirty utility area, and neither area shall be located in or open into a kitchen, dining room and should not open into a bathroom. The facility shall have utility areas that are easily available to personnel and located conveniently for the nursing station staff. Utility area shall be well-ventilated and well-lighted. II/III
13. (26) The facility shall provide either a nursing station or a nurses’ work area on each floor of a multistory facility. This area shall have chart storage space on current residents. Facilities licensed or with plans approved on or after July 1, 1965, shall have a nurses’ station for every sixty (60) beds. Handwashing facilities at or near the nurses’ station shall be available for physicians, nurses and other personnel attending residents. II/III
14. (27) The facility shall be equipped with a call system that consists of an electrical intercommunication system, a buzzer system or hand bells for each resident bed, toilet room and bathroom. II/III
15. (28) The heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or warm air systems employing either central heating plants with installation so as to safeguard the inherent fire hazard or outside wall heaters with approved installation. Portable heater use is prohibited. Facilities shall provide adequate guards to safeguard residents where potential burn hazards exist. I/II
16. (29) The facility shall ensure that each room or ward in which residents are housed or to which residents have reasonable access shall be capable of being heated to not less than eighty degrees Fahrenheit (80°F) at the winter design temperature. Room temperature shall not be lower than sixty-eight degrees Fahrenheit (68°F), but the reasonable comfort needs of individual residents shall be met. I/II
17. (30) Facilities shall use air-conditioning units, a central air-conditioning system, fans or a ventilating system when the room temperature exceeds eighty-five degrees Fahrenheit (85°F) to meet the reasonable comfort needs of individual residents. I/II
18. (31) Lighting shall be restricted to electricity. Electrical wiring and equipment shall be installed and maintained in accordance with nationally recognized safety practices. In facilities with plans approved on or after January 1, 1999, compliance with the 1996 National Electrical Code, shall be considered compliance with the previously mentioned practices. Every two (2) years a qualified electrician will be required to certify in writing that the electrical system is being maintained and operated in accordance with the standards outlined by the 1996 National Electrical Code, incorporated by reference in this rule. In facilities whose plans were approved on or before December 31, 1998, the electrician shall comply with the requirements of the National Electrical Code as referenced in the 1985 Life Safety Code. II/III
19. (32) The facility shall provide lighting with a minimum intensity of ten (10) footcandles in hallways, bathrooms, recreational, dining and all resident-use areas. III
20. (33) Facilities shall use night-lights in hallways, resident rooms, toilet rooms or bathrooms and on stairways. II
21. (34) The facility shall ensure that a reading light is provided for each resident who desires to read. III
22. (35) To prevent direct glare to residents’ eyes, facilities shall ensure that lights in residentuse areas have a shade or dome. III
23. (36) If elevators are used, their installation and maintenance shall comply with all local and state codes and the 1996 National Electrical Code, which is incorporated into this rule by reference, for facilities whose plans were approved on or after January 1, 1999. In facilities whose plans were approved on or before December 31, 1998, the elevators shall comply with applicable local and state codes and the requirements of the National Electrical Code as referenced in the 1985 Life Safety Code. II
24. (37) If extension cords are used, they must be Underwriters’ Laboratories (UL)-approved and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord. Only two (2) appliances may be served by one (1) duplex receptacle. Extension cords shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/III
25. (38) The facility shall maintain furniture and equipment in good condition and shall replace it if broken, torn, heavily soiled or damaged. Rooms shall be designed and furnished so that the comfort and safety of the residents are provided for at all times. II/III
26. (39) Rooms shall be neat, orderly and cleaned daily. II/III
27. (40) The facility shall ensure that each resident shall be provided an individual bed, single or twin, in good repair of rigid type. Beds shall be at least thirty-six inches (36") wide. Double beds of satisfactory construction may be provided for married couples. Rollaway, metal cots or folding beds shall not be used. II/III
28. (41) A minimum of three feet (3') shall be available between parallel beds. III
29. (42) Mattresses shall be clean, in good repair, sized to fit the bed and a minimum of four inches (4") in thickness to provide comfort. II/III
30. (43) The facility shall ensure that each bed has at least one (1) clean comfortable pillow. Extra pillows shall be available to meet the needs of the residents. III
31. (44) Multi-bed resident rooms shall have screens or curtains, either portable or permanently affixed, available and used to provide privacy as needed or as requested. III
32. (45) Facilities shall provide each resident with an individual locker or other suitable space for storage of clothing and personal belongings. III
33. (46) The facility shall provide residents with an individual rack for towels and washcloths unless they are provided with clean washcloths or towels for use each time needed. III
34. (47) A comfortable chair shall be available for each resident’s use. III

AUTHORITY: section 198.079, RSMo 1994.* Original rule filed July 13, 1983, effective Oct. 13, 1983. Emergency amendment 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, effective Dec. 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 July 30, 1999. * Original authority 1979.