Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to manage his or her financial affairs.

Based on interview and record review the facility failed to ensure the availability of
petty cash on an ongoing basis. This affected two residents (Resident #88 and #92) out of
a sample of 21 residents, with the potential to affect all residents. The facility census
was 105.
During an interview on 2/05/19 at 10:56 A.M., Resident #92 said the residents’ personal
funds are only available at the receptionist’s desk in the front lobby, Monday through
Friday at 8:00 A.M. through 11:00 A.M. If he/she doesn’t remember to get money in the
mornings, then he/she doesn’t have any money for later in the day. If he/she forgets to
get money on Friday morning, then he/she doesn’t have any money for the weekend.
During the resident council group meeting on 2/05/19 at 3:00 P.M., Resident #88 said the
residents’ personal funds are only available Monday through Friday at 8:00 A.M. through
11:00 A.M. and their money is unavailable at any other time.
During an interview on 2/07/19 at 9:29 A.M., Receptionist D said the resident banking
hours are Monday through Friday at 8:00 A.M. through 11:00 A.M. The banks around this area
are closed on the weekends so the facility does not provide money to the residents on the
weekend either. If a resident needs money for the weekend, they need to get it before
11:00 A.M. on Friday. They do have some residents that aren’t happy with this arrangement,
but that is just the way they do.
During an interview on 2/07/19 at 10:15 A.M., the Business Office Manager (BOM) said the
resident banking hours are Monday through Friday at 8:00 A.M. through 11:00 A.M. The
residents’ personal funds aren’t available to the residents on the weekends due to it is
locked up in the safe in his/her office and no one has access to it.
During an interview on 2/08/19 at 9:15 A.M., the Administrator said she would expect the
personal funds to be available to the residents at their convenience. She said the banking
hours have always been Monday through Friday at 8:00 A.M. through 11:00 A.M.
The facility did not provide a policy on petty cash/resident personal funds.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure the accuracy of a
resident’s advance directive regarding resuscitation status for three residents (Resident
#38, #87, and #92) out of a sample of 21 residents. The facility census was 105.
1. Record review of Resident #38’s Physician order [REDACTED].
– No code (does not want any resuscitation measures taken) status.
Record review of the resident’s Advance Directive Form, dated [DATE], showed:
– Resident wanted cardiopulmonary resuscitation (CPR) to be performed.
Record review of the resident’s care plan, revised [DATE], showed:
– Full code status.
Record review of the resident’s face sheet, dated [DATE], showed:
– Full code status, dated [DATE].
Observation of the resident’s medical record on [DATE] at 11:46 A.M., showed:
– Full code status written under the resident’s name on the spine of the chart.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
2. Record review of Resident #87’s POS, dated [DATE] through [DATE], showed:
– Do not resuscitate (DNR).
Record review of Resident #87’s Advance Directive Form, dated [DATE], showed:
– Resident #87 desired CPR to be performed.
Record review of Resident #87’s care plan updated [DATE] showed:
– DNR.
Record review of Resident #20’s face sheet showed:
– DNR.
3. Record review of Resident #92’s POS, dated [DATE] through [DATE], showed:
– DNR code status.
Record review of the resident’s Outside the Hospital Do Not Resuscitate (OHDNR) form,
dated [DATE], showed:
– Resident wanted DNR code status.
Record review of the resident’s care plan, revised [DATE], showed:
– Full code status.
Record review of the resident’s face sheet, dated [DATE], showed:
– Full code status, dated [DATE].
Observation of the resident’s medical record on [DATE] at 11:15 A.M., showed:
– DNR code status written under the resident’s name on the spine of the chart.
During an interview on [DATE] at 2:35 P.M., Certified Nurse Aide (CNA) C said he/she
checks the spine of the chart for the resident’s code status.
During an interview on [DATE] at 2:40 P.M., Licensed Practical Nurse (LPN) F said he/she
checks the spine of the chart for the code status of a resident, but the code status is
also located on the POS.
During an interview on [DATE] at 8:41 A.M., the Director of Nursing (DON) said she would
expect the resident’s correct code status to be documented on all documents in the medical
record.
During an interview on [DATE] at 9:15 A.M., the Administrator said she would expect the
correct code status to be on all the resident’s personal and medical information.
The facility did not provide a policy regarding advance directives.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to issue Notice of Medicare
Non-Coverage (NOMNC) letters when the resident’s Medicare covered services had ended for
three residents (Resident #46, #83, and #106) and to continue to provide and bill the
resident’s Medicare covered services per the resident’s choice for two residents (Resident
#46 and #83) out of three sampled residents. The facility census was 105.
1. Review of Resident #46’s medical record showed:
– The resident discharged from Medicare A skilled services on 12/08/18 and days remained
in the benefit period;
– The facility failed to issue a NOMNC letter;
– The facility failed to provide and bill the Medicare A skilled services, per the
resident’s choice, after the facility discharged the services.
Record review of the resident’s Skilled Nursing Facility Advance Beneficiary Notice (SNF

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
ABN) letter showed:
– The resident chose to continue to receive the Medicare A skilled services after his/her
discharge on 12/08/18 with Medicare to be billed for an official decision on the payment;
– If Medicare doesn’t pay for the skilled service, the resident can appeal the decision to
Medicare.
2. Review of Resident #83’s medical record showed:
– The resident discharged from Medicare A skilled services on 12/06/18 and days remained
in the benefit period;
– The facility failed to issue a NOMNC letter;
– The facility failed to provide and bill the Medicare A skilled services, per the
resident’s choice, after the facility discharged the services.
Record review of the resident’s SNF ABN letter showed:
– The resident chose to continue to receive the Medicare A skilled services after his/her
discharge on 12/06/18 with Medicare to be billed for an official decision on the payment;
– If Medicare doesn’t pay for the skilled service, the resident can appeal the decision to
Medicare.
3. Review of Resident #106’s medical record showed:
– The resident discharged from Medicare A skilled services on 11/21/18 and days remained
in the benefit period;
– The facility failed to issue a NOMNC letter.
During an interview on 2/07/19 at 9:08 A.M., the Social Service Designee (SSD) said he/she
was instructed, per their corporate person, to not complete the NOMNC letters when a
resident discharged from Medicare A skilled services. He/she was instructed that only the
SNF ABN forms were to be given. On the SNF ABN forms, the residents have the choice of
whether they want to continue to receive Medicare A services after they are discharged
from these services by the facility, and if they want to appeal if Medicare denied their
covered services after the discharge. He/she realized that Resident #46 and #83 chose to
continue to receive their Medicare A skilled services after the facility discharged them
from the Medicare A services, but he/she doesn’t know what happened after they made the
decision as far as the billing or the continuation of the Medicare A skilled services.
He/she doesn’t take care of the appeal process. He/she thinks the residents do not
understand the different options they are presented with prior to discharge from skilled
services.
During an interview on 2/07/19 at 11:21 A.M., the Business Office Manager (BOM) said
he/she does the resident billing, but doesn’t do anything with the continued billing of
the Medicare A skilled services during the appeal process or anything to do with the
appeal process. The SSD takes care of all of that.
During an interview on 2/08/19 at 9:15 A.M., the Administrator said she would expect the
correct forms to be completed for the liability notices when a resident is discharged from
Medicare A skilled services. She would expect the Medicare A skilled services to continue
to be billed and the appeal process completed, if the resident chose to continue to
receive the Medicare A skilled services after they were discharged by the facility and
Medicare denied the claim. She thinks the residents do not understand the different
options they are presented with prior to discharge from the skilled services.
The facility did not provide a policy for the liability notices.

F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not transfer or discharge a resident without an adequate reason; and must provide
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
documentation and convey specific information when a resident is transferred or
discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to provide a resident with an
appropriate Immediate Discharge Notice for one resident (Resident #206). The facility
census was 105.
Record review of Resident #206’s medical chart showed an admitted to the facility on
[DATE] from the hospital.
Record review of the Immediate Discharge Notice, dated 1/29/19, issued to the resident
showed:
– The safety of other residents and staff must be adhered to;
– The facility is charged with protective oversight of all residents;
– The facility was made aware by the resident and the Missouri State Highway Patrol Sex
Offender Registry that the resident is a registered Offender;
– The facility does not accept sex offender in the facility;
– The resident was issued a warrant on 1/14/19 for failure to appear on assault 4th
degree;
– The facility attempted to find placement for the resident had been unsuccessful;
– The facility discharged the resident to hospital.
Record review of the Resident #206 appeal letter, dated 1/29/19, showed:
– The notice form the facility to the resident did not contain a statement, informing
Resident of the effective date of the transfer or discharge.
– The notice from the facility to the resident did not contain a statement, informing the
resident that filing appeal will allow a resident to remain in the facility until the
hearing is held unless a hearing official finds otherwise.
– The notice from the facility to the resident did not contain a statement, informing the
resident the location to which the resident is being transferred or discharged .
– The Facility’s notice is determined to be invalid.
– The facility has provided invalid notice, the notice to the resident concerning his
possible discharge is dismissed.
Record review of the Resident face sheet showed he/she readmitted to the facility on
[DATE].
During an interview on 2/07/19 at 10:15 A.M., with Resident #206 he/she said when he/she
informed the Administrator that he/she needed to register as a sex offender the
Administrator informed him/her that he/she could not live at the facility. The
Administrator told him/her that they would transport him/her back to the hospital and he
could stay there until the hospital found him/her a different placement. Resident #206
said the social worker at the hospital said the facility could not discharge him/her in
this manner and assisted him in filing an appeal. The appeal was dismissed and he/she was
allowed to return to the facility. Resident #206 said since returning to the facility he
has been comfortable and no one has made him/her feel uncomfortable. He/she said that he
likes it here and can tell that he/she is feeling better since he has been getting proper
medication and nutrition.
During an interview on 2/07/19 at 9:30 A.M. with the Administrator she said that when the
referral was received they were not informed of the resident’s history and they failed to
complete their own background check at the facility. Since this occurred the facility has
revised their admission checklist to ensure proper screening has been completed prior to
accepting a new resident.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
The facility did not provide a policy on immediate discharge/ transfer.
MO 275

F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and/or
the resident’s representative in writing of a transfer or discharge to a hospital,
including the reason for transfer and failed to notify the Office of the State Long-Term
Ombudsman (an advocate for residents in a long-term care facility) for four residents
(Resident #46, #83, #99, and #105) out of six sampled residents transferred to the
hospital. The facility census was 105.
1. Record review of Resident #46’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE].
Review of the resident’s record showed:
– No documentation of a letter notifying the resident and/or the resident’s representative
of the resident’s transfer to the hospital on [DATE] and 1/23/19;
– No documentation of notification of the Ombudsman’s office regarding the resident’s
transfers to the hospital.
2. Record review of Resident #83’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE].
Record review of the resident’s medical record showed:
– No documentation of a letter notifying the resident and/or the resident’s representative
of the resident’s transfer to the hospital on [DATE];
– No documentation of notification of the Ombudsman’s office regarding the resident’s
transfer to the hospital.
3. Record review of Resident #99’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE].
Record review of the resident’s medical record showed:
– No documentation of a letter notifying the resident and/or the resident’s representative
of the resident’s transfer to the hospital on [DATE];
– No documentation of notification of the Ombudsman’s office regarding the resident’s
transfer to the hospital.
4. Record review of Resident #105’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and did not return to the facility.
Record review of the resident’s medical record showed:
– No documentation of a letter notifying the resident and/or the resident’s representative
of the resident’s transfer to the hospital on [DATE].
During an interview on 2/06/19 at 3:40 P.M., the Director of Nursing said she would expect
staff to provide a written statement for the reason for the hospital transfer to the
resident and/or the resident’s representative.
During an interview on 2/07/19 at 9:37 A.M., the Social Service Director said he/she was
not aware he/she needed to notify the Ombudsman office of each resident’s transfer to the
hospital.
During an interview on 2/07/19 at 2:28 P.M., the Administrator said she would expect the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 5)
Ombudsman office to be notified when residents are transferred to the hospital.
The facility did not provide a policy on written resident transfer notice.

F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and/or
the resident’s representative of the facility bed hold policy at the time of transfer to
the hospital for four residents (Resident #46, #83, #99, and #105) of six sampled
residents for bed hold policy.
1. Record review of Resident #46’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE].
Review of the resident’s record showed no documentation of the bed hold policy provided to
the resident and/or the resident’s representative at the time of the transfers.
2. Record review of Resident #83’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE].
Record review of the resident’s medical record showed no documentation of the bed hold
policy provided to the resident and/or the resident’s representative at the time of the
transfer.
3. Record review of Resident #99’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE].
Record review of the resident’s medical record showed no documentation of the bed hold
policy provided to the resident and/or the resident’s representative at the time of the
transfer.
4. Record review of Resident #105’s nurse’s notes showed:
– Resident transferred to the hospital on [DATE] and did not return to the facility.
Record review of the resident’s medical record showed no documentation of the bed hold
policy provided to the resident and/or the resident’s representative at the time of the
transfer.
During an interview on 2/7/19 at 2:26 P.M., the Director of Nursing said she expects staff
to provide information regarding the facility’s bed hold policy at the time of the
transfer to the resident and/or the resident’s representative. She expects staff to
document the bed hold policy was provided.
The facility did not provide a policy on bed hold.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, observation, and record review, the facility failed to follow the
physician’s orders for one resident (Resident #154) from a sample of 21 residents. The
facility census was 105.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
1. Record review of Resident #154’s admission Minimum Data Set (MDS), dated [DATE],
showed:
– Brief interview for mental status (BIMS) not conducted, resident rarely understood;
– [DIAGNOSES REDACTED].
– [MEDICAL CONDITION] ( muscle weakness or [DIAGNOSES REDACTED] on one side of the body
that can affect the arms, legs, and facial muscles);
– Total dependence of one/two persons for all activities of daily living (ADL);
– Malnutrition;
– Feeding tube, 51% or more total calories received through tube feeding;
– At risk of developing pressure ulcers;
– Care area of pressure ulcer triggered and care planned.
Record review of Resident #154’s physicians order sheet (POS), dated (MONTH) 1019, showed,
float heels while in bed.
Observation on 2/5/19 at 9:44 A.M., Resident #154 in bed with heels not covered or
floated.
Observation on 2/6/19 at 2:22 P.M., resident in bed with heels not covered or floated.
Observation on 2/7/19 at 5:45 P.M., resident in bed with heels not covered or floated.
During an interview on 2/7/19 at 2:45 P.M., Certified Nursing Aide (CNA) G said he/she put
some cream on Resident #154’s heels today because they were dry. They never have put
his/her heels on a pillow. Sometimes the CNAs use heel protectors for other residents, but
Resident #154 would probably kick them off.
During an interview on 2/7/19 at 4:40 P.M., Registered Nurse (RN) B said she would expect
the CNAs to float the resident’s heels since it was an order in the POS.
During an interview on 2/7/19 at 5:05 P.M., the Director of Nursing (DON) said he/she
would expect physicians orders to be done.
A facility policy regarding following the physician’s orders was not provided.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
appropriate care practices related to an indwelling catheter (a tube inserted into the
urinary bladder) for two residents (Resident #28 and #304) out of two sampled residents
for indwelling catheters. The facility census was 105.
1. Observation on 2/07/19 at 8:50 A.M., showed:
– Resident #304 lay in bed with an indwelling catheter;
– Certified Nurse Aide (CNA) C transferred the resident to his/her wheelchair;
– CNA C placed the resident’s catheter bag (a bag with tubing that connects to the
indwelling catheter, used to collect urine) into a privacy bag on the back of the
resident’s wheelchair with catheter tubing touching the floor;
– CNA C, with catheter tubing dragging across the floor, rolled the resident in his/her
wheelchair to the dining room/activity room.
Observation on 2/07/19 at 9:40 A.M., showed the resident sat in the dining room/activity
room with catheter tubing touching floor.
Observation on 2/08/19 8:52 A.M., showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
– Resident sat in his/her wheelchair with catheter bag in a privacy bag on the back of the
wheelchair with catheter tubing touching the floor;
– The resident rolled his/her wheelchair on top of the catheter tubing;
– He/she reached down and removed the catheter tubing from under the wheelchair wheel;
– He/she rolled him/herself down the hallway to dining room/activity room with the
catheter tubing dragging the floor.
2. Observation on 2/7/19 at 9:10 A.M., showed:
– Resident #28 lay in bed with an indwelling catheter with catheter bag and tubing in a
trash can beside the bed;
– CNA C provided catheter care;
– CNA C did not clean the entire perineal area or the catheter tubing;
– CNA C removed catheter bag and tubing from the trash can and placed on the side of the
bed.
Observation on 2/8/19 at 8:50 A.M., showed:
– Resident lay in bed with an indwelling catheter with catheter bag and tubing in a trash
can beside the bed that contained a milk carton, papers, and candy wrappers.
During an interview on 2/7/19 at 9:30 A.M., CNA C said he/she was taught to clean just the
catheter insertion site and not the entire area or catheter tubing. He/she said a
resident’s catheter bag should not be placed in a trash can because it is unclean.
During an interview on 2/8/19 at 8:58 A.M., CNA C said a resident’s catheter tubing should
not touch the floor.
During an interview on 2/8/19 at 9:05 A.M., Licensed Practical Nurse (LPN) A said a
resident’s catheter tubing should not touch the floor and a catheter bag should not be
placed in a trash can.
During an interview on 2/8/19 at 9:10 A.M., Director of Nursing (DON) said she expects
staff to clean the entire perineal area and the catheter tubing. She said a resident’s
catheter tubing should not touch the floor. The DON said staff should not place a
resident’s catheter bag in a trash can. She expects staff to hang the catheter bag on the
side of the bed.
Record review of the facility’s Insertion and Care of an Indwelling Urinary Catheter
policy, undated, showed:
– Starting at the urethral opening and moving outward, using gentle circular [MEDICAL
CONDITION], cleanse the area;
– The urethral opening must always be cleaned first;
– Cleanse the entire perineum;
– Holding the catheter firmly, without tugging, start at the urethral opening and cleanse
the catheter approximately 5 inches down from the urethral opening.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish a written agreement
with a [MEDICAL TREATMENT] center and provide documentation of ongoing assessment,
monitoring, and communication between the facility and the [MEDICAL TREATMENT] center for
two residents (Resident #26 and #57) out of two sampled residents receiving [MEDICAL
TREATMENT] (process for removal of waste and excess water from the blood due to kidney
failure). The facility census was 105.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
1. Record review of the facility’s written agreement with [MEDICAL TREATMENT] center
showed:
– No written agreement between the facility and the [MEDICAL TREATMENT] center.
2. Record review of Resident #26’s (MONTH) 2019 Physician order [REDACTED].
– admitted to the facility on [DATE];
– [DIAGNOSES REDACTED].
– [MEDICAL TREATMENT] on Monday, Wednesday, and Friday;
– An order on 3/13/18 to check for bruit (audible vascular sound) and thrill (vibration
felt on the skin) of the fistula ([MEDICAL TREATMENT]) every shift;
– No orders to assess and monitor the resident before and after a [MEDICAL TREATMENT]
treatment.
Review of the resident’s care plan, revised 3/06/18, showed:
– Generalized weakness after [MEDICAL TREATMENT];
– Monitor access site every day;
– Monitor for bruit and thrill daily;
– Monitor and report signs of localized infection.
Record review of the resident’s medical record (MONTH) 1, (YEAR) through (MONTH) 7, 2019,
showed:
– No documentation to assess and monitor the resident’s condition before and after
[MEDICAL TREATMENT] treatments;
– No documentation of communication between the facility and the [MEDICAL TREATMENT]
staff.
3. Record review of Resident #57’s (MONTH) 2019 POS showed:
– admitted to the facility on [DATE];
– [DIAGNOSES REDACTED].
– [MEDICAL TREATMENT] on Monday, Wednesday, and Friday;
– An order on 4/16/18 to check for bruit and thrill of the fistula every shift;
– No orders to assess and monitor the resident before and after a [MEDICAL TREATMENT]
treatment.
Review of the resident’s care plan, revised 9/19/18, showed:
– [MEDICAL TREATMENT] on Monday, Wednesday, and Friday;
– Fistula in resident’s right arm;
– Monitor [MEDICAL TREATMENT] for signs and symptoms of infection and notify physician if
observed;
– Monitor for bruit and thrill and notify physician if absent.
Record review of the resident’s medical record (MONTH) 1, (YEAR) through (MONTH) 7, 2019,
showed:
– No documentation to assess and monitor the resident’s condition before and after
[MEDICAL TREATMENT] treatments;
– No documentation of communication between the facility and the [MEDICAL TREATMENT]
staff;
– No documentation of staff checking for bruit and thrill in the month of (MONTH) 2019.
During an interview on 2/7/19 at 10:36 A.M., Registered Nurse (RN) B said the facility and
the [MEDICAL TREATMENT] staff do not routinely communicate with each other before and
after the resident’s [MEDICAL TREATMENT] treatments. He/she said the facility does not
have a tool for communication. If the [MEDICAL TREATMENT] center did call, the nurse would
document in the nursing notes. RN B said nurses do not assess the resident before and
after [MEDICAL TREATMENT] treatment. He/she said the resident’s [MEDICAL TREATMENT] site
is checked for bruit and thrill every shift and would be documented on the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
treatment administration record if completed.
During an interview on 2/7/19 at 12:20 P.M., the Director of Nursing (DON) said the
facility does not send any written communication regarding the resident to [MEDICAL
TREATMENT] and the [MEDICAL TREATMENT] does not send any written communication when the
resident returns to the facility. The facility and [MEDICAL TREATMENT] center communicate
only when needed by phone and the nurse would document in the nursing notes. The DON said
she would expect the facility and [MEDICAL TREATMENT] staff to communicate the resident’s
care and status. She would expect staff to assess, monitor, and document the status of the
resident and his/her [MEDICAL TREATMENT].
During an interview on 2/7/19 at 2:19 P.M., the Administrator said the facility does have
some agreements with [MEDICAL TREATMENT] centers but did not have an agreement with this
[MEDICAL TREATMENT] center. The administrator said the facility should have an agreement
with each [MEDICAL TREATMENT] center that residents use
The facility did not provide a policy on [MEDICAL TREATMENT].

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation and interview, the facility failed to post the nurse staffing data in
a clear and readable format in a prominent place readily accessible to residents and
visitors on a daily basis at the beginning of each shift. This deficient practice had the
potential to affect all residents in the facility. The facility census was 105.
1. Observations on 2/04/19, 2/05/19, 2/06/19, and 2/07/19, showed:
– The daily assignment sheet posted did not include the facility’s name, total number of
Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA),
and the total number of hours worked by RN, LPN, and CNA.
During an interview on 2/7/19 at 11:05 A.M., the Director of Nursing said she only posts
the daily assignment sheet. She did not know the facility should also post the total
number of RN, LPN, and CNA along with the total number of hours each worked on each shift.
The facility did not provide a policy on posting nurse staffing data.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the pharmacy
consultant identified an appropriate [DIAGNOSES REDACTED]. Medication Regimen Review (MRR)
for one resident (Resident #38) out of five sampled residents. The facility census was
105.
1. Record review of Resident #38’s Physician order [REDACTED].
– [DIAGNOSES REDACTED].
– an order for [REDACTED].>- an order for [REDACTED].
Record review of the resident’s POS, dated 2/1/19 – 2/28/18, showed:
– an order for [REDACTED].>- an order for [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
Record review of the pharmacist’s monthly MMR, dated 1/22/18 through 1/17/19, showed:
– No request from the pharmacist for further documentation from the physician in regards
to an appropriate [DIAGNOSES REDACTED].
– No request from the pharmacist for a GDR of the [MEDICATION NAME].
During an interview on 2/06/19 at 3:30 P.M., Licensed Practical Nurse (LPN) I said the
resident’s medication order dates had been changed to 1/31/19 due to he/she had recently
been hospitalized and returned to the facility on [DATE]. The [MEDICATION NAME] was
reduced to 0.25 mg once daily with lunch for [MEDICAL CONDITION] on 1/31/19. The original
start date for the [MEDICATION NAME] was 2/28/17, and it hasn’t been reduced since the
original start date. The facility could not find a GDR request for the [MEDICATION NAME]
since it was started on 2/28/17.
During an interview on 2/08/19 at 8:41 A.M., the Director of Nursing (DON) said she would
expect the pharmacist to make recommendations on [MEDICAL CONDITION] medications for an
appropriate [DIAGNOSES REDACTED]. She would expect the physician to prescribe and document
an appropriate [DIAGNOSES REDACTED]. She said the consultant pharmacist that comes to the
facility now is new so he/she isn’t the same one that had been doing the MMR’s.
The facility did not provide a policy for an appropriate [DIAGNOSES REDACTED].

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure an appropriate
[DIAGNOSES REDACTED].#38) out of five sampled residents. The facility census was 105.
1. Record review of Resident #38’s Physician order [REDACTED].
– [DIAGNOSES REDACTED].
– an order for [REDACTED].>- an order for [REDACTED].
Record review of the resident’s POS, dated 2/1/19 – 2/28/18, showed:
– an order for [REDACTED].>- an order for [REDACTED].
Record review of the pharmacist’s monthly medication review (MMR), 1/22/18 through
1/17/19, showed:
– No request from the pharmacist for further documentation from the physician in regards
to an appropriate [DIAGNOSES REDACTED].
– No request from the pharmacist for a GDR of the [MEDICATION NAME].
Record review of the resident’s medical record showed:
– No attempt by the physician for an appropriate [DIAGNOSES REDACTED].
– No attempt by the physician for a GDR of the [MEDICATION NAME].
Record review of Mosby’s (YEAR) Nursing Drug Reference for [MEDICATION NAME] showed:
– Contraindications for geriatric patients;
– Black box warning increased mortality in elderly patients with dementia-related [MEDICAL
CONDITION].
During an interview on 2/6/19 at 3:30 P.M., Licensed Practical Nurse (LPN) I said the
resident’s medication order dates had been changed to 1/31/19 due to he/she had recently
been hospitalized and returned to the facility on [DATE]. The [MEDICATION NAME] was
reduced to 0.25 mg once daily with lunch for [MEDICAL CONDITION] on 1/31/19. The original

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
start date for the [MEDICATION NAME] was 2/28/17, and it hasn’t been reduced since the
original start date. The facility could not find a GDR request for the [MEDICATION NAME]
since it was started on 2/28/17.
During an interview on 2/8/19 at 8:41 A.M., the Director of Nursing (DON) said she would
expect the physician to prescribe and document an appropriate [DIAGNOSES REDACTED].
The facility did not provide a policy for an appropriate [DIAGNOSES REDACTED].

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to maintain proper
refrigerator temperatures in the medication storage room. This practice affected two
residents ( Residents #18 and #83) from a sample of 21 residents and three residents (#39,
#41, and #96) outside the sample. The facility census was 105.
Observation on 2/07/19 at 9:51 A.M., of the medication storage refrigerator on 100 hall
showed:
– Temperature at 26 degrees Fahrenheit (F);
– Temperature of refrigerator confirmed by Licensed Practical Nurse (LPN) F;
– Contents of the refrigerator included insulins for Resident #18, one [MEDICATION NAME]
10 milliliter (ml) vial; Resident #39, one [MEDICATION NAME] 10 ml vial, three [MEDICATION
NAME] 9 ml [MEDICATION NAME], and three [MEDICATION NAME] 3 ml FlexTouch; Resident #41,
one [MEDICATION NAME] 10 ml vial; Resident #83, one [MEDICATION NAME] 10 ml vial; and
Resident #96, one [MEDICATION NAME] R 500 u/ml Kwikpen and one Tresiba 3 ml FlexTouch;
– Two [MEDICATION NAME] purified protein derivative ( an injectable used to diagnose
[MEDICAL CONDITION]) 1 ml vials;
– Two [MEDICATION NAME] quadrivalent (an influenza vaccine) 5 ml vials;
– Ten [MEDICATION NAME] (a medication taken for relief of pain and fever) suppositories
650 milligrams (mg).
Record review of the (MONTH) 2019 temperature log for the Medication storage refrigerator
on 100 hall refrigerator showed:
– On 2-01-19 temperature of 31 degrees F;
– On 2-02-19 temperature of 30 degrees F;
– On 2-03-19 temperature of 32 degrees F;
– On 2-04-19 temperature of 31 degrees F;
– No recordings for 2-05-19 or 2-06-19.
Record review of the Food and Drug Administration, requirements for medication storage
showed, insulins and other medications requiring refrigeration are to be kept at
temperatures above 36 degrees F and below 46 degrees F, in order to insure the medications
are effective, stable and undamaged until the expiration dates.
During an interview on 2/7/19 at 10:00 A.M., LPN F said it was the night shift nurse’s
responsibility to check and record the refrigerator temperatures.
During an interview on 2/7/19 at 10:10 A.M., the Director of Nursing (DON) said it was all
the nurses’ responsibility to monitor the temperatures and alert maintenance of
refrigerators not functioning properly.
A facility policy on the storage of medications was not provided.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Employ sufficient staff with the appropriate competencies and skills sets to carry out
the functions of the food and nutrition service, including a qualified dietician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to have
sufficient, competent food service staff. This practice effected all residents in the
facility. The facility census was 105.
Record review of the Facility assessment dated [DATE] showed the following:
– Staffing Plan/Position- Dietitian or other clinically qualified nutrition professional
to serve as the director of food and nutrition services;
– Additional references to the Facility Assessment defines Food and Nutrition Services
Staffing as the facility must employ sufficient staff members with the appropriate
competencies and skills to carry out the functions of the food and nutrition service,
taking into consideration resident assessments, individual plans of care and the number,
acuity and [DIAGNOSES REDACTED].
During an interview on 2/07/19 at 1:00 P.M., the Food Service Director said he was not a
Certified Dietary Manager. He said the Registered Dietitian comes to the facility and
reviews the resident charts but he has not had very much interaction with her. He said he
started his employment on 1/07/19.
During an interview with the Administrator 02/08/19 09:17 AM she was unaware of the
Certified Dietary Manager requirement but they are working to ensure compliance.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to store, prepare, distribute, and
serve food under sanitary conditions, potentially affecting all residents. The facility
census was 105.
1. Observation in the kitchen on 2/07/19 at 9:00 A.M. – 12:30 P.M., showed:
– A build up of grease on both sides of the stove;
– Dirt and debris on the floor behind the stove area;
– Dirt and debris on the floor under the stove area;
– Dirt and debris under the dishwashing machine;
– Blackened and burned areas around the edges of 12 baking pans;
– Blackened and burned areas around the edges of 10 steam table pans;
– Two vanilla ice cream cups lay on the floor in the walk in freezer unit;
– Missing floor covering on the floor and threshold in the walk in freezer unit;
– Food crumbs and debris lay on the floor in the food storage rooms;
– Dirt and grease build up on the floor under the food prep island;
– Dirt and grease build up on three fans in the food prep and dishwashing areas;
– All rolling food carts had food particle build up on the rails;
– Blackened burned areas and food particles in the oven and the oven doors.
During an interview on 2/07/19 at 12:00 P.M., the Food Service Director said he was in
agreement that the identified areas were in need of cleaning or repair.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 13)
During an interview on 2/07/19 at 12:30 P,M, the Administrator said she is in agreement
that the identified areas are in need of cleaning or replace/repair. She said they would
get the areas cleaned up and repaired/replaced to ensure compliance.
The facility did not provide a cleaning schedule or policy.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

Based on observation, interview, and record review, the facility failed to maintain
infection control practices for two residents (Resident #5 and #28) out of 21 sampled
residents and one resident (#22) outside the sample for infection control. The facility
census was 105.
1. Observation on 2/07/19 at 9:10 A.M., showed:
– Resident #28 lay in bed with an indwelling catheter (a tube inserted into the bladder to
drain the bladder);
– Certified Nurse Aide (CNA) C provided catheter care for the resident;
– CNA C, with soiled gloves, touch the resident’s shorts, sheets, and blanket;
– CNA C, with soiled hands, exited the resident’s room.
During an interview on 2/7/19 at 9:30 A.M., CNA C said he/she was taught to wash hands
before care, after care, and before leaving the resident’s room. He/she said he/she should
not have touched clean items with soiled gloves or hands.
During an interview on 2/08/19 at 9:10 A.M., the Director of Nursing (DON) said she
expects staff to clean hands before care, after removing gloves, and before leaving a
resident’s room. She said she expects staff not to touch clean items with soiled gloves or
hands.
Record review of the facility’s Handwashing policy, dated 4/4/18, showed handwashing is
done before and after resident care, during resident care when glove changes are made, or
at any time hands become soiled.
2. Observation on 2/07/19 at 11:39 A.M., showed:
– LPN F gather supplies in order to perform finger stick blood glucose readings;
– LPN F wiped the glucometer (a blood glucose monitoring device) with a Micro Kill
disinfecting wipe for 5 seconds;
– LPN F laid the glucometer on a paper towel;
– LPN F gathered the lancet, inserted the test strip into the glucometer and carried them
to Resident # 22’s room;
– LPN F obtained the blood glucose reading;
-LPN F returned to the medication cart and wiped the glucometer with a Micro Kill
disinfecting wipe for 4 seconds and laid the glucometer on the paper towel;
– LPN F administered insulin to Resident #22;
– LPN F gathered the glucometer and entered Resident #5’s room and obtained a blood
glucose reading;
– LPN F returned to the medication cart and wiped the glucometer with a Micro Kill
disinfecting wipe for 4 seconds and laid it on the paper towel.
Record review of the Micro Kill disinfecting wipe label showed:
– To disinfect hard, non-porous surface must be kept wet with the wipe for two minutes and
allowed to air dry;
– Micro Kill Disinfecting Wipes with alcohol are effective against blood borne pathogens

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
when used as directed.
During an interview on 2/7/19 at 12:00 P.M., LPN F said he/she had been using them
incorrectly. He/she thought that letting air dry for two minutes was the proper way to
disinfect.
During an interview on 2/7/19 at 4:50 P.M., the DON said he/she would expect the nurses to
read the instructions on how to disinfect properly.
A facility policy for glucometer disinfection was not provided.

F 0883

Level of harm – Potential for minimal harm

Residents Affected – Many

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide information and
education to each resident or the resident’s representative of the pneumococcal vaccines,
and offer the pneumococcal vaccines upon admission to three residents (Resident #17, #28,
and #29) out of five sampled resident. This deficient practice had the potential to affect
all residents. The facility census was 105.
1. Review of the US Department of Health and Human Services Centers for Disease Control
(CDC) Pneumococcal Vaccine Timing for Adults dated 11/30/15 showed the following:
– CDC recommends two pneumococcal vaccines for adults: 13-valent pneumococcal conjugate
vaccine (PCV 13, Prevnar 13) and 23-valent pneumococcal vaccine (PPSV 23, [MEDICATION
NAME] 23);
– CDC recommends vaccination with PCV 13 for all adults [AGE] years or older and adults 19
through [AGE] years old with certain medical conditions:
– CDC recommends vaccination with PPSV 23 for all adults [AGE] years or older and adults
19 through [AGE] years old with certain medical conditions.
2. Review of Resident #17’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtained a signed consent/refusal form for PCV 13.
3. Review of Resident #28’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtained a signed consent/refusal form for PCV 13.
4. Review of Resident #29’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265395

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/08/2019

NAME OF PROVIDER OF SUPPLIER

CORI MANOR HEALTHCARE & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

560 CORISANDE HILLS ROAD
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 15)
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtained a signed consent/refusal form for PCV 13.
5. During an interview on 2/7/19 at 11:15 A.M., the Minimum Data Set (MDS) (a federally
mandated assessment instrument completed by the facility staff) Coordinator said the
facility has been offering the [MEDICATION NAME] 23 vaccine but not the PCV 13. She said
the facility has not provided residents and/or representative any information regarding
the pneumococcal vaccines. She said she tries to find out a new resident’s pneumococcal
vaccine history within the first week of admission.
During an interview on 2/7/19 at 2:00 P.M., the Director of Nursing said the facility has
not been offering PCV 13 vaccine to residents. She said she expects staff to document a
resident’s pneumococcal vaccine history, provide education, obtain consent to receive for
both types of pneumococcal vaccine.
The facility did not provide a policy on pneumococcal vaccines.