CORI MANOR HEALTHCARE & REHABILITATION CENTER

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.

**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.

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

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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.

**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

**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.

**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.

**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:

**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.

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.

**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].

**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

**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.

**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.

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.

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

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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