Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to review and
revise four residents’ (Residents #16, #35, #36, and #64) plans of care to ensure the plan
accurately reflected the residents’ needs. The facility census was 71.
1. Review of Resident #16’s Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 11/20/18, showed staff assessed the resident as:
– Received scheduled pain medication;
– Received PRN (as needed) pain medication;
– Had occasional pain in the past five days.
Review of the resident’s Medication Administration Record (MAR) and Treatment
Administration Record (TAR), dated (MONTH) (YEAR), showed staff documented the resident
had pain on the following dates: 11/1, 11/2, 11/3, 11/4, 11/5, 11/6, 11/7, 11/9, 11/10,
11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23,
11/24, 11/25, 11/26 and 11/27 (26 out of 30 days). Further, review showed staff gave the
resident PRN (as needed) medication for pain on the following dates: 11/1, 11/2, 11/4,
11/5, 11/6, 11/7, 11/9, 11/11, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/21,
11/22 and 11/23 (18 out of 30 days).
Review of the resident’s MAR and TAR, dated (MONTH) (YEAR), showed staff documented the
resident had pain on the following dates: 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9,
12/10, 12/11, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22,
12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29 and 12/30 (29 out of 31 days). Review
showed an order started on 12/3/18, for staff to give the resident [MEDICATION
NAME]-[MEDICATION NAME] (an opioid pain medication) 5-325 MG scheduled every 6 hours for
severe pain.
Review of the resident’s MAR and TAR, dated (MONTH) 2019, showed staff documented the
resident had pain every day that month (31 out of 31 days). Review showed an order for
[REDACTED]. In addition, review showed an order, started on 1/11/19, for staff to give the
resident [MEDICATION NAME] HCL (an opioid pain medication) 50 mg every eight hours
scheduled for pain.
Review of the resident’s MAR and TAR, dated (MONTH) 2019, showed for the dates of 2/1/19
through 2/12/19 staff documented the resident had pain on 2/1, 2/2, 2/4, 2/5, 2/6, 2/7,
2/8, 2/9, 2/10, 2/11 and 2/12. Review showed an order for [REDACTED]. In addition, review
showed an order, started on 1/11/19, for staff to give the resident [MEDICATION NAME] HCL
(an opioid pain medication) 50 mg every eight hours scheduled for pain.
Review of the resident’s care plan, initiated 8/14/18, showed staff did not update the
resident’s care plan to include the resident had pain and did not include any
interventions for pain.
During an interview on 2/14/19 at 5:15 P.M., Licensed Practical Nurse (LPN) A said the
resident gets scheduled pain medication for severe pain.
During an interview on 2/14/19 at 7:00 P.M., the MDS Coordinator said pain should be
addressed on the resident’s care plan.
During an interview on 2/14/19 at 7:30 P.M., the Director of Nursing (DON) said pain
should be addressed on the resident’s care plan. Further, the DON said the resident has
abdominal pain because he/she has a hernia.
2. Review of Resident #64’s most recent MDS, dated [DATE], showed staff assessed the
resident as:
-Dependent on staff assistance for bed mobility, transfers, locomotion on and off the

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 1 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
unit, dressing, and toilet use;
-Weight loss of 5% or more in the last month or 10% or more in the last 6 months;
-At risk of developing pressure ulcers;
-No unhealed pressure ulcers.
Observation on 2/12/19 at 5:22 P.M., showed Certified Nurse Aide (CNA) C and CNA D
provided perineal cleansing and repositioning for the resident, who lay in bed.
Observation at that time showed an open pressure ulcer on the resident’s right lower
buttock.
Review of the resident’s progress notes showed on 2/4/19, staff documented they found a
dime sized open area 0.5 centimeters (cm) x 0.5 cm, location not documented; the resident
refused to lay on his/her side. Staff noted they applied protective ointment. Review
showed on 2/5/19, staff documented they notified the nurse practitioner regarding the area
on the resident’s buttock reopening.
Review of the resident’s weight records showed the resident had a weight loss of greater
than 10% in the last six months of weights recorded.
Review of the resident’s plan of care for his/her activities of daily living (ADL)
deficit, revised on 5/16/17, showed:
-The resident was dependent on staff for ADLs;
-The resident was able to feed him/herself with setup;
-The resident ate in both his/her room and the main dining room;
-The plan did not direct staff in any care or interventions to address the resident’s
weight loss. Staff did not document that the resident ate better if he/she got out of bed
for meals.
Review of the resident’s plan of care to address the resident’s right sided [MEDICAL
CONDITION] (weakness on one side of the body), revised on 12/19/17, showed:
-The resident was incontinent of bowel and bladder;
-The resident was at risk for pressure ulcers and moisture associated [MEDICAL CONDITION];
-The plan directed staff to apply barrier cream after perineal care, turn and reposition
the resident, and check for bowel and bladder incontinence and provide timely care;
-The plan did not address the resident’s current open pressure ulcer on the right buttock.
During an interview on 2/14/19 at 7:16 P.M., the MDS Coordinator said if a resident has a
risk of skin breakdown and a new wound opens, he/she tries to get the wound and
interventions on the care plan. The MDS Coordinator said he/she reviews the wound care
company’s documentation and adds anything new to the care plans.
During an interview on 2/14/19 at 3:38 P.M., the DON said staff watched the resident
closely for weight loss. The DON said the resident suffered two bouts of pneumonia and had
no appetite, and staff had to feed the resident for a while when he/she was weak. The
dietician recommended med pass supplement for the resident and that was increased over
time. Other interventions for staff include encouraging the resident to get out of bed for
meals, as he/she eats better when out of bed. At 7:21 P.M., the DON said the MDS
Coordinator is responsible to update residents’ care plans. The DON said staff discuss
issues during their morning meetings and the MDS Coordinator is at those meetings and this
is one of the ways he/she gets the information. The DON said weight loss and a resident’s
specific open skin areas should be documented on the care plan. The DON said the wound
care company usually sees all residents with open areas, but did not see Resident #64
because the nurse practitioner said it was not necessary as the area was a small open area
the staff could treat with barrier cream.
3. Review of Resident #35’s MDS, dated [DATE], showed staff assessed the resident as
follows:
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 2 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-Required extensive assistance from staff with personal hygiene and dressing;
-Dependent upon staff with bed mobility, transfers and toileting;
-Uses wheelchair;
-Always incontinent of bowel and bladder;
-At risk for the development of pressure ulcers;
-No pressure ulcer at any stage;
-Pressure relieving device on bed and chair.
Review of the resident’s comprehensive care plan, dated 2/7/18, directed staff on the
following interventions for the prevention of the development of pressure ulcers:
-Apply barrier cream with incontinent care;
-Offer the bedpan frequently;
-Provide peri-care with each incontinent episode;
-Encourage and assist resident to turn and reposition in bed;
-Weekly skin assessments.
Further review of the comprehensive care plan showed staff did not update to include
interventions for the treatment and assessment of the coccyx open areas identified by
staff on 1/19/19.
Review of the most recent Braden Scale (scale used to indicate risks of the development of
pressure ulcers) showed staff scored the resident a 14 which indicates him/her at moderate
risk for the development of pressure ulcers.
Review of the nurse’s notes, dated 1/19/19, showed staff documented the resident had 3
areas noted to coccyx measured in box formation with measurements being 1.8 cm
(centimeter) x 2.1 cm x 0.7 cm.
Review of the physician’s orders [REDACTED].
Review of the weekly skin assessments, dated 1/19/19, showed staff documented that staff
identified three small open areas on the right buttock Further, staff documented that
treatment orders were received and implemented. Review of the weekly skin assessments
showed staff did not document any skin assessments prior to 1/19/19 or after 1/19/19.
Observation on 2/14/19 at 1:30 P.M., showed the resident lay in bed. CNA F assisted the
resident onto his/her side. Observation showed a circular, open area to the right buttocks
measuring approximately 1.5 cm in length. Observation showed the open area as a Stage II
(partial thickness open area) pressure ulcer.
4. Review of Resident #36’s quarterly MDS assessment, dated 12/18/18, showed staff
assessed the resident as follows:
-Short and long term memory loss;
-Dependent upon staff for bed mobility, transfers, dressing, eating, toilet use and
personal hygiene;
-Weight is 171 lbs.;
-Not on a weight loss regimen;
-Feeding tube;
-Mechanically altered diet;
-Receives more than 51% of total calories through a feeding tube.
Review of the resident’s comprehensive care plan, revised 10/25/18, directed staff on the
following interventions for the tube feeding:
-Dependent with tube feeding and water flushes. See orders for current feeding orders;
-Check placement prior to all flushes/feedings. Administer tube feedings per medications
administration record;
-Registered Dietician to evaluate quarterly and as needed. Monitor caloric intake,
estimate needs, make recommendations for changes to tube feedings as needed;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 3 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Report to physician signs and symptoms of aspiration as needed;
Further review of the resident’s comprehensive care plan showed staff did not include
interventions for planned weight loss.
Review of the resident’s monthly weights showed the resident weighed 178.8 in (MONTH)
(YEAR) and 166.6 in (MONTH) 2019.
Review of the Registered Dietician’s (RD) progress notes, dated 2/7/19, showed the
resident’s current weight at 166.6 lbs and gained 8.6 lbs in last three months and lost 7
lbs in last six months. The RD documented the resident continued to be offered a puree
diet. RD documented the resident continues to be given 60 milliliter (ml) of 2 cal (oral
supplement) three times a day. The RD documented to prevent excess weight gain suggest to
discontinue the oral supplement and monitor weight weekly and decrease bolus feedings if
indicated.
5. During an interview on 02/14/19 at 6:52 P.M., the MDS Coordinator said she is
responsible for updating the care plans. Further, the MDS Coordinator said staff are
expected to write down changes on a communication sheet so that she is made aware of
changes. The MDS Coordinator said she would expect planned weight loss and an open wound
to have interventions on the resident’s comprehensive care plan.
6. During an interview on 2/14/19 at 7:21 P.M., the DON said the MDS Coordinator said the
MDS Coordinator is responsible for updating residents’ care plans. The MDS Coordinator
attends the morning stand-up meeting where staff talk about any resident changes.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to administer
residents’ medications per physician’s orders for eight residents (Residents #1, #3, #16,
#24, #28, #30, #51, and #64). Facility staff also failed to document wound assessments for
one resident (Resident #35) and failed to document a physician’s order for one resident’s
(Resident #173) tube feeding rate. The facility census was 71.
1. Review of Resident #24’s medical record showed the resident’s [DIAGNOSES
REDACTED].>-[MEDICAL CONDITIONS];
-Muscle weakness;
-Difficulty walking;
-Kidney failure;
-Dementia without behavioral disturbance;
-Major [MEDICAL CONDITION];
-Diabetes mellitus without complications;
-Hypertension;
-History of falling;
-[MEDICAL CONDITION] (a disease in which increased pressure damages the eye’s optic
nerve).
Review of the resident’s medication administration record (MAR), dated (MONTH) 2019,
showed:
-A physician’s order for [MEDICATION NAME] (used to treat increased eye pressure caused by
[MEDICAL CONDITION]) solution 22.3-6.8 milligrams/milliliter (mg/ml), instill one drop in

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 4 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
both eyes two times a day for [MEDICAL CONDITION];
-Staff did not document administration of the medication and instead documented a 9 on
1/2/19, 1/6/19, 1/7/19 (am and pm dose), 1/9/19, 1/11/19, 1/12/19, 1/13/19; 1/14/19,
1/16/19, 1/18/19, 1/19/19 and 1/21/19 (a total of 13 times).
Review of the resident’s progress notes from (MONTH) 2019 showed no documentation to
support why staff did not administer the resident’s [MEDICATION NAME] on these dates.
During an interview on 2/14/19 at 10:07 A.M., Certified Medication Technician (CMT) B said
when the resident was first admitted , the pharmacy didn’t send the resident’s [MEDICATION
NAME] eye drops. The CMT said staff at the facility went back and forth with the pharmacy,
and finally received the [MEDICATION NAME] drops. The CMT said he/she did not know why
some days staff documented they gave the eye drops and other days staff documented the eye
drops were unavailable. During an observation at that time, the CMT showed the surveyor
the bottle of [MEDICATION NAME] eye drops and the bag which contained the bottle which
showed a date of 12/1/18. The CMT said that is the day the pharmacy would have sent the
medication.
During an interview on 2/14/19 at 10:33 A.M., the Director of Nurse’s (DON) said he/she
was not aware that the resident’s [MEDICATION NAME] eye drops were ever missing or
unavailable. The DON said if a medication is unavailable, the CMT should tell the charge
nurse, who will contact the pharmacy. The DON said the charge nurses give her report and
should tell her of problems obtaining a medication from the pharmacy. The DON said it
looked as if the CMTs were trying to handle the issue and not reporting it to the
appropriate staff.
Review of the resident’s MAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the medication was not given for the following medications
on 2/9/19:
-[MEDICATION NAME] (treatment for [REDACTED].
-[MEDICATION NAME] (medication for high blood pressure) 2.5 mg;
-[MEDICATION NAME] 100 mg (medication for high blood pressure);
-[MEDICATION NAME] (used to prevent and treat low Vitamin B12 levels) 1000 micrograms
(mcg);
-Folic acid (a vitamin) 1 mg;
-[MEDICATION NAME] (a diuretic) 20 mg;
-[MEDICATION NAME] solution 22.3-6.8 milligrams/milliliter (mg/ml) (am dose);
-Cranberry tablet (a supplement) 450 mg (am dose);
-Memantine HCL (used to treat moderate to severe confusion) 50 mg (am dose);
Additional review showed staff did not document administration or a reason why the
medication was not given for [MEDICATION NAME] sodium (used to treat low [MEDICAL
CONDITION] hormone levels) 50 mcg. on 2/10/19 and 2/11/19.
2. Review of Resident #28’s MAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the medication was not given for the following medications
on 2/9/19:
-[MEDICATION NAME] (a diuretic) 20 mg;
-Eliquis (a blood thinner) 5 mg;
-[MEDICATION NAME] (a muscle relaxant) 10 mg (am and noon doses);
-[MEDICATION NAME] (an anticonvulsant) 300 mg (am and noon doses).
Review of the resident’s progress notes for 2/9/19 showed no notes regarding why staff did

not document administration of the resident’s am and noon medications on that date.
During an interview on 2/12/19 at 9:17 A.M., Resident #28 said there have been problems

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 5 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
getting medications on time. The resident said he/she believes this is because the
medication machine breaks down. The resident said staff have told the residents that the
machine jams up. The resident said this happens once every couple of weeks. On 2/13/19 at
11:03 A.M., the resident said this past Saturday (2/9/19), he/she did not receive his/her
morning medications. The resident said the staff member responsible for passing
medications (CMT B) arrived to work late, around 9:00 A.M., and the second staff member
responsible for passing medications did not show up. Therefore, CMT B had to pass
medications for the whole building. The resident said he/she did not receive any
medications that day until around 4:30 P.M.-5:00 P.M.
3. Review of Resident #16’s MAR, dated (MONTH) 2019, showed staff did not document
medication administration or a reason why the medication was not given for the following
medications on 2/9/19:
– [MEDICATION NAME] (medication for high blood pressure) 5 mg;
– Aspirin 81 mg;
– B-Complex/Vitamin C Tablet;
– [MEDICATION NAME] HCL (antidepressant) 50 mg;
– AM dose of Apixaban (anticoagulant) 2.5 mg;
– AM dose of Carvedilol (medication for high blood pressure) 25 mg;
– AM dose of [MEDICATION NAME] (medication for constipation) 625 mg;
– AM dose of Losartan (medication for high cholesterol) 25 mg;
– AM dose of [MEDICATION NAME] HCL (medication for acid reflux) 150 mg;
– 8:00 A.M. and 12:00 P.M. doses of Calcium Acetate (given for elevated [MEDICATION NAME]
in the blood) 667 mg.
4. Review of the facilities Liberalized Med Pass Times, undated, showed the following:
– AM Med Pass is 6:00 A.M. – 10:59 A.M.;
– Noon Med Pass is 11:00 A.M. – 2:00 P.M.;
– PM Med Pass is 2:01 P.M. – 7:00 P.M.;
– HS Med Pass is 7:01 P.M. to 11:00 P.M.;
– TID (three times daily) is AM, noon and PM;
– QID (four times daily) is AM, noon, PM and HS;
– These medication times will be followed unless physician ordered specific medication
pass times.
5. Review of the chart codes on the MAR and TAR for the facility showed the following:
– 1 = Absent from home without meds;
– 2 = Drug Refused;
– 3 = Absent from home with meds;
– 4 = Vitals Outside of Parameters for Administration;
– 5 = Hold/See Progress Notes;
– 6 = hospitalized ;
– 7 = Sleeping;
– 8 = Nauseated/Vomiting;
– 9 = Other/See Progress Notes.
6. Review of the Resident #30’s current physician orders showed an order for [REDACTED].
Review of the resident’s MAR, dated (MONTH) 2019, showed an order for [REDACTED]. The
medication times scheduled on the MAR were AM, noon, PM and HS.
During an interview on 2/11/19 at 2:25 P.M., the resident said he/she takes [MEDICATION
NAME] for [MEDICAL CONDITION] pain. He/she gets [MEDICAL CONDITION] pain when not given
the [MEDICATION NAME] timely. Staff do not always give him/her the [MEDICATION NAME]
timely.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 6 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
Review of resident’s MAR, dated (MONTH) 2019, showed staff did not document medication
administration or a reason why the medication was not given for the following on 2/9/19:
– [MEDICATION NAME] (medication for high blood pressure) 10 MG;
– Losartan Potassium (medication for high blood pressure) 50 MG;
– Multivitamin;
– AM dose of [MEDICATION NAME] (antidepressant) 60 MG;
– AM dose of Levetiracetam ([MEDICAL CONDITION] medication)1000 MG;
– AM and noon doses of [MEDICATION NAME] HCL (vitamin) 100 MG;
– AM and noon doses of [MEDICATION NAME] (medication for [MEDICAL CONDITION]) 600 MG.
7. Review of Resident #51’s MAR, dated (MONTH) 2019, showed staff did not document
medication administration or a reason why the medication was not given for the following
medications on 2/9/19:
– Aspirin 81 mg;
– [MEDICATION NAME] Propionate Suspension (nose spray) 50 MCG/ACT;
– TAB-A-VITE (multivitamin) + IRON;
– Vitamin B12 500 MCG;
– Vitamin D3 2000 Units;
– AM dose of [MEDICATION NAME] Tablet 650 mg;
– AM dose of [MEDICATION NAME] (medication for tremors) 0.5 mg;
– AM dose of [MEDICATION NAME] DR 500 mg (medication for [MEDICAL CONDITION]);
– AM dose of [MEDICATION NAME] [MEDICATION]) 500 MG;
– Noon dose of [MEDICATION NAME] (medication for [MEDICAL CONDITION])100 MG.
8. Review of Resident #64’s MAR showed the resident’s physician ordered medications which
included:
-Oyster shell calcium with Vitamin D 500 mg, three times daily; the MAR showed scheduled
times of am, noon, and pm;
-[MEDICATION NAME] (an anticonvulsant) 400 mg, three times daily; the MAR showed scheduled
times of am, noon and pm.
Observations of the resident’s medication administration by CMT B on 2/12/19 at 11:20
A.M., showed CMT B gave the resident’s medications to be given three times daily, per the
liberalized medication pass times:
-Oyster shell calcium/Vit D 500 mg, one tablet;
-[MEDICATION NAME] 400 mg, one tablet.
9. Review of Resident #1’s medical record showed the resident’s [DIAGNOSES
REDACTED].>-[MEDICAL CONDITION];
-Binge eating disorder;
-[MEDICAL CONDITION];
-[MEDICAL CONDITION];
-Multiple injuries;
-Major [MEDICAL CONDITION];
-Diabetes mellitus;
-Acute [MEDICAL CONDITION];
-Heart failure;
-[MEDICAL CONDITION];
-Type 2 Diabetes Mellitus;
-Hypertension (HTN);
-[MEDICAL CONDITION];
-Gastro-[MEDICAL CONDITION] reflux disease;
-Anxiety disorder.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 7 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed staff did not document
administration or a reason why the medication was not given for the following medications
on:
-12/7/18, [MEDICATION NAME] 50 mcg for dry nasal passages;
-12/8/18, [MEDICATION NAME] 40 mg for cholesterol;
-12/8/18, [MEDICATION NAME] 50 mg for hypertension (PM dose);
-12/8/18, [MEDICATION NAME] 100 mg for weight control (PM dose);
-12/8/18, [MEDICATION NAME] 50 mg for weight control (PM dose);
-12/8/18, [MEDICATION NAME] 20 mg for muscle spasms (PM dose);
-12/9/18, [MEDICATION NAME] 112 mcg for [MEDICAL CONDITION];
-12/9/18, Magnesium Oxide 400 mg for heart failure (PM dose).
Review of the resident’s TAR, dated (MONTH) (YEAR), showed staff did not document
administration or a reason why the medication was not given for the following treatments
on:
-12/6, 12/7, 12/9, 12/21/18, [MEDICATION NAME] Sodium Gel 1% for pain;
-12/6, 12/7, 12/9, 12/17, 12/21, 12/24, 12/29/18, No-sting skin-prep to left buttock for
wound care;
-12/6, 12/7, 12/9, 12/17, 12/21, 12/24, 12/29/18, No-sting skin-prep to left posterior
thigh for wound care;
-12/6, 12/7, 12/9, 12/17, 12/21, 12/24, 12/29/18, No-sting skin-prep to right posterior
thigh for wound care;
-12/6, 12/7, 12/17, 12/17, 12/21, 12/24, 12/29/18, Santyl Ointment 250 Unit/gm to left
lower leg for wound care.
Review of the resident’s MAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the medication was not given on 1/14/18, [MEDICATION NAME]
112 mcg for [MEDICAL CONDITION].
Review of the resident’s TAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the medication was not given for the following treatments
on:
-1/17, 1/31/19, [MEDICATION NAME] solution inject 1 mg every 2 weeks for Vitamin B12
deficiency;
-1/4, 1/11, 1/16/19, [MEDICATION NAME] Sodium Gel 1% for pain;
-1/1, 1/4, 1/11, 1/16, 1/23/19, No-sting skin-prep to left buttock for wound care;
-1/1, 1/4, 1/11, 1/16, 1/23, 1/24/19, No-sting skin-prep to left posterior thigh for wound
care;
-1/1, 1/4, 1/11, 1/16, 1/23, 1/24/19, No-sting skin-prep to right posterior thigh for
wound care;
-1/1, 1/4, 1/8, 1/11, 1/16, 1/23, 1/24, 1/25, 1/31/19, Santyl Ointment 250 Unit/gm to left
lower leg for wound care;
-1/22/19, Tresiba FlexTouch Solution Pen-injector 20 units in evening (PM) for diabetes;
-1/4, 1/11, 1/16/19, Tresiba FlexTouch Solution Pen-injector 20 units in morning (AM) for
diabetes;
-1/4, 1/11, 1/16/19, [MEDICATION NAME] Solution Pen-injector 1.8 mg one time daily (QD)
for DM 2;
-1/2/19 bedtime (HS), 1/4/19 (AM), 1/11/19 (AM), [MEDICATION NAME] 0.25 mg for major
[MEDICAL CONDITION];
-1/4, 1/11/19, [MEDICATION NAME] HCL 30 mg for moderate to severe pain (8:00 AM dose);
-1/4/19 (8:00 AM and 12:00 PM dose), 1/11/19 (8:00 AM dose), 1/16/19 (8:00 AM dose),
1/26/19 (5:00 PM dose), [MEDICATION NAME] Solution per sliding scale for DM.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 8 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
Review of the resident’s MAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the medication was not given for the following medications
on:
-2/1/19, [MEDICATION NAME] 40 mg HS for cholesterol;
-2/1/19, Bactrim DS tablet 800-160 mg for bacterial infection/UTI (8:00 PM dose);
-2/1/19, [MEDICATION NAME] 20 mg for muscle spasms (HS dose).
Review of the resident’s TAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the medication was not given for the following treatments
on:
-2/8/19, Tresiba FlexTouch Solution Pen-injector 70 units HS for Type 2 diabetes mellitus;
-2/8/19, [MEDICATION NAME] 0.25 mg for major [MEDICAL CONDITION] (HS dose);
-2/8/19, [MEDICATION NAME] HCL 30 mg for moderate to severe pain (8:00 PM dose).
10. Review of Resident #3’s medical record showed the resident’s [DIAGNOSES
REDACTED].>-Major [MEDICAL CONDITION];
-[MEDICAL CONDITION];
-Hypertension;
-[MEDICAL CONDITION];
-Metabolic [MEDICAL CONDITION];
-Dysphagia;
-Hyperosmolality and [MEDICAL CONDITION];
-Rhabdomyolysis;
-[MEDICAL CONDITION];
-[MEDICAL CONDITION];
-Malnutrition;
-Dementia;
-Gastrostomy;
-Kidney failure.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed staff did not document
administration or a reason why the house supplement 60 ml for med pass was not given on
12/23/18 (PM dose), 12/25/18 (AM and noon dose), 12/26/18 (PM dose), 12/31/18 (noon dose).
Review of the resident’s TAR, dated (MONTH) (YEAR), showed staff did not document
administration or a reason why the medication was not given for the following treatments
on:
-12/9/18, [MEDICATION NAME] 10 mg via [DEVICE] QD for HTN;
-12/9/18, Aspirin 325 mg via [DEVICE] QD to prevent clots;
-12/3, 12/17, 12/28, 12/31/18, Atorvastatin calcium 10 mg via [DEVICE] HS for cholesterol;
-12/9/18, [MEDICATION NAME] bisulfate 75 mg via [DEVICE] QD to prevent clots;
-12/9/18, Donepezil HCL 10 mg via [DEVICE] QD for dementia;
-12/9/18, [MEDICATION NAME] 4 mg via [DEVICE] QD for HTN;
-12/9/18, First-omepra 20 ml via [DEVICE] QD for GERD;
-12/9/18, Vitamin D3 1000 unit via [DEVICE] QD for supplement
-12/8/18 (PM dose), 12/9/18 (AM dose), 12/18/18 (PM dose), 12/30-31/18 (PM dose),
[MEDICATION NAME] 7.5 ml via [DEVICE] two time daily (BID) for [MEDICAL CONDITION];
-12/9/18 (12:00 PM) Enteral feed order BID one can [MEDICATION NAME] 1.5 per [DEVICE];
-12/3/18 (PM dose), 12/9/18 (AM dose), 12/17/18 (PM dose), 12/30-31/18 (PM dose),
[MEDICATION NAME] tablet 12.5 mg via [DEVICE] BID for major [MEDICAL CONDITION].
Review of the resident’s MAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the house supplement 60 ml for med pass was not given on
1/22/19 (PM dose), 1/25/19 (AM and noon dose), 1/28/19 (AM and noon dose), 1/31/19 (AM and
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 9 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
noon dose).
Review of the resident’s TAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the medication was not given for the following treatments
on:
-1/2, 1/22, 1/31/19, Atorvastatin calcium 10 mg via [DEVICE] HS for cholesterol;
-1/2/19 (PM dose), 1/31/19 (PM dose), [MEDICATION NAME] 7.5 ml via [DEVICE] BID for
[MEDICAL CONDITION];
-1/2/19 (PM dose), 1/22/19 (PM dose), [MEDICATION NAME] tablet 12.5 mg via [DEVICE] BID
for major [MEDICAL CONDITION].
Review of the resident’s MAR, dated (MONTH) 2019, showed staff did not document
administration or a reason why the house supplement 60 ml for med pass was not given on
222/19 (AM and noon dose), 2/3/19 (AM and noon dose), 2/6-7/19 (AM and noon dose), 2/9/19
(AM and noon dose).
11. During an interview on 2/14/19 at 10:15 A.M., the DON said the following:
– The facility went to using liberalized med pass times because of the pharmacy they use;
– If a resident takes a medication three or four times a day they should probably schedule
more specific times for these and not go with the liberalized med pass so as to space out
the medication throughout the day.
12. During an interview on 2/14/19 at 1:30 P.M., CMT B said the following:
– If staff do not document the administration of a scheduled medication on the MAR or TAR
then they are supposed to document why the medication was not given. If it’s not
documented then it’s not given.
– He/she worked on the day shift on 2/9/19 and 2/10/19. It was very busy that day. She
gave the residents their medications on 2/9 and 2/10 but she may have forgot to sign them
off and that’s why there are blanks on the MARs/TARs for those dates;
– He/she tries to make sure to space out scheduled medications a resident gets several
times a day. If he/she gave a resident a morning dose of a medication at 10:00, then
he/she wouldn’t give the next dose until 1:30.
13. During an interview on 2/14/19 at 7:30 P.M., the DON said the following:
– If a medication is not given, staff should document why it was not given in a progress
note;
– If staff do not document they gave a medication then it is considered not given because
she cannot prove they gave it.
14. Review of Resident #35’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 12/15/19, showed staff assessed the resident as follows:
-Required extensive assistance from staff with personal hygiene and dressing;
-Dependent upon staff with bed mobility, transfers and toileting;
-Uses wheelchair;
-Always incontinent of bowel and bladder;
-At risk for the development of pressure ulcers;
-Did not have any pressure ulcers;
-Pressure relieving device on bed and chair.
Review of the resident’s comprehensive care plan, dated 2/7/18, directed staff on the
following interventions for the prevention of the development of pressure ulcers:
-Apply barrier cream with incontinent care;
-Offer the bedpan frequently;
-Provide peri-care with each incontinent episode;
-Encourage and assist resident to turn and reposition in bed;
-Weekly skin assessments.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 10 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
Further review of the comprehensive care plan showed staff did not update to include
interventions for the treatment and assessment of the coccyx open areas identified by
staff on 1/19/19.
Review of the most recent Braden Scale (scale used to indicate risks of the development of
pressure ulcers) showed staff scored the resident a 14 which indicated he/she was at
moderate risk for the development of pressure ulcers.
Review of the nurse’s notes, dated 1/19/19, showed staff documented the resident had three
areas noted to coccyx measured in box formation with measurements being 1.8 cm
(centimeter) x 2.1 cm x 0.7 cm .
Review of the Physician’s Order Sheet (POS), dated (MONTH) 2019 showed staff obtained an
order on 1/20/19 from the physician for [MEDICATION NAME] (barrier ointment used to
protect and help skin irritations) Ointment to be applied to the buttocks topically as
needed.
Review of the weekly skin assessments, dated 1/19/19, showed staff documented that staff
identified three small open area on the right buttock Further, staff documented treatment
orders were received and implemented. Review of the weekly skin assessments showed staff
did not document any skin assessments prior to 1/19/19 or after 1/19/19.
Review of the resident’s medical record showed staff did not document a weekly wound
assessment after staff identified the open areas to the buttocks on 1/19/19.
Review of the TAR, dated (MONTH) 2019, showed staff did not document they applied
[MEDICATION NAME] to the buttocks from 1/20/19-1/31/19.
Review of the TAR, dated (MONTH) 2019, showed staff did not include or document skin
assessments as completed. Further review of the TAR showed staff did not document they
applied [MEDICATION NAME] to the buttocks during any of the days from 2/1/19-2/14/19.
Observation on 2/14/19 at 1:30 P.M., showed the resident lay in bed. Certified Nurse Aide
(CNA) F assisted the resident onto his/her side. Observation showed a circular, open area
to the right buttocks measuring approximately 1.5 cm in length. Observation showed the
open area as a Stage II (partial thickness open area) pressure ulcer.
During an interview on 2/14/19 at 7:21 P.M., the DON said the professional staff are
expected to do a weekly skin assessment on every resident and document it in the medical
record. Further, if a resident has an open area, then staff are expected to do a wound
assessment and refer them to the mobile wound center for ongoing weekly assessment and
treatment. The DON said she was not aware the resident had an open area. The DON said
currently the resident has not been referred to the mobile wound center.
15. Review of Resident #173’s medical record showed the resident was admitted to the
facility on [DATE].
Observations during the survey on 2/13/19 at 9:00 A.M. and 2/14/19 at 9:37 A.M. showed the
resident lay in bed, with [MEDICATION NAME] 1.5 tube feeding infusing per pump at 60
cc/hour.
Review of the resident’s TAR, dated (MONTH) 2019, showed an order for [REDACTED]. Review
showed no rate of flow for the resident’s tube feeding liquid.
During an interview on 2/14/19 at 11:31 A.M., Licensed Practical Nurse (LPN) E said the
resident’s tube feeding rate should be listed on the TAR. The LPN said nursing staff
checks the resident’s tube feeding rate against the TAR on each shift. Upon reviewing the
resident’s TAR, the LPN said the staff member who entered the order into the system did
not add the resident’s tube feeding rate. The LPN reviewed the resident’s hospital
discharge orders and his/her paper medical record and did not find the admitting orders
with a rate for the resident’s [MEDICATION NAME]. The LPN did find documentation from the
resident’s previous facility that showed he/she received [MEDICATION NAME] 1.5 at 60 cc
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 11 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
per hour at the previous facility. At 2:41 P.M., the LPN said he/she contacted the nurse
practitioner (NP) and received a clarification order for the resident’s [MEDICATION NAME]
1.5 to run at 60 cc/hr.
During an interview on 2/14/19 at 7:21 P.M., the DON said staff the admitting nurse
received a verbal order for the [MEDICATION NAME] rate of 60 cc/hr and did not document
the order. The DON said staff should document the rate on the orders and TAR.

F 0697

Level of harm – Actual harm

Residents Affected – Few

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to consistently
provide routine pain medication and failed to address pain on the resident’s care plan for
one resident (Resident #16) who frequently had pain. The facility census was 71.
1. Review of the chart codes on the MAR and TAR for the facility showed if a medication
was not administered, staff were to document one of the following:
– 1 = Absent from home without meds;
– 2 = Drug Refused;
– 3 = Absent from home with meds;
– 4 = Vitals Outside of Parameters for Administration;
– 5 = Hold/See Progress Notes;
– 6 = hospitalized ;
– 7 = Sleeping;
– 8 = Nauseated/Vomiting;
– 9 = Other/See Progress Notes.
Review of the resident’s Minimum Data Set, a federally mandated assessment instrument,
dated 11/20/18, showed staff assessed the resident as:
– Received an opioid seven out of the last seven days;
– Received [MEDICAL TREATMENT];
– Received scheduled pain medication;
– Received PRN (as needed) pain medication;
– Had occasional pain in the past five days.
Review of the resident’s care plan, initiated 8/14/18, showed staff documented the
resident had behaviors of refusing medications, refusing [MEDICAL TREATMENT] and being
resistive to care; the resident’s overall demeanor is angry and grumpy. Staff were
directed to observe behavioral episodes and attempt to determine underlying cause and
remove hindrance if possible. Review showed staff did not update the resident’s care plan
to include the resident had pain and did not include any interventions for pain.
Review of the resident’s Medication Administration Record (MAR) and Treatment
Administration Record (TAR), dated (MONTH) 2019, showed the following:
– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 on 1/6, 1/13, 1/15, 1/19, 1/20 1/23, 1/27 and 1/30 (a total
of eight times);
– An order (dated 1/11/19) for [MEDICATION NAME] (an opioid pain medication) 50 mg
scheduled to be given by mouth every eight hours for pain. Staff did not document the
administration of the medication and instead documented a code of 9 twice on 1/12, on
1/14, 1/20, 1/21 and 1/28 (a total of six times);

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 12 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 12)
– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 twice on 1/1, twice on 1/2, 1/19, twice on 1/21, on 1/23,
three times on 1/24, three times on 1/25, twice on 1/26, twice on 1/27 and twice on 1/29
(a total of 20 times);
– Staff documented the resident had pain every day this month (31 out of 31 days).
Review of the resident’s progress notes for (MONTH) 2019 showed staff documented the
following:
– 1/1 at 4:57 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/1 at 6:50 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/2 at 5:12 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/2 at 5:13 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/2 at 12:25 P.M. – [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg given. Spoke with
physician and made aware of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg not available.
Received a new order for [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg to be given by
mouth every six hours until the dosage of 5-325 mg comes in from pharmacy;
– 1/2 at 6:03 P.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg came in, order for
[MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg discontinued;
– 1/3 at 8:51 A.M. – Called [MEDICAL TREATMENT] to inform them the resident is refusing
[MEDICAL TREATMENT] treatment today. The resident is cursing and yelling;
– 1/6 at 10:06 P.M. – [MEDICATION NAME] 75 mg on order;
– 1/9 at 9:03 P.M. – [MEDICATION NAME] 75 mg medication not given on order;
– 1/12 at 5:20 A.M. – [MEDICATION NAME] HCL 50 mg New order. Awaiting delivery;
– 1/12 at 5:38 P.M. – [MEDICATION NAME] HCL 50 mg Medication isn’t available;
– 1/13 at 9:54 P.M. – Staff did not document why the [MEDICATION NAME] was not given;
– 1/14 at 6:49 A.M. – [MEDICATION NAME] HCL 50 mg Medication was n/a;
– 1/15 at 1:08 P.M. – Resident refused to go to [MEDICAL TREATMENT] today. Staff educated
the resident on the importance of keeping the scheduled [MEDICAL TREATMENT] treatments and
the resident started yelling and cursing. The resident continues to be verbally abusive
toward staff when asked if he/she needs any assistance with activities of daily living.
The resident continues to reject care at times;
– 1/15 at 7:44 P.M. – Staff did not document why the [MEDICATION NAME] was not given;
– 1/19 at 12:59 P.M. – Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME]
5-325 mg was not given;
– 1/19 at 8:48 P.M. – [MEDICATION NAME] 75 mg on order;
– 1/20 at 4:32 A.M. – Staff did not document why the [MEDICATION NAME] HCL 50 mg was not
given;
– 1/20 at 11:59 P.M. – [MEDICATION NAME] 75 mg on order;
– 1/21 at 4:04 A.M. – [MEDICATION NAME] HCL 50 mg Medication not available;
– 1/21 at 6:40 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order;
– 1/21 at 6:43 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Med N/a;
– 1/21 at 12:51 P.M. – Pain noted of 10/10 on pain scale. The resident is in bed and
states left arm in excruciating pain. Nurse tried to touch the resident’s left arm and the
resident yelled out in pain. Scheduled pain medication was given at 11:00 A.M.;
– 1/21 at 1:17 P.M. – Notified physician of the resident’s left arm pain. Received a new
order for an x-ray to left arm and for staff to give a dose of [MEDICATION
NAME]-[MEDICATION NAME] 5-325 now for pain.
– 1/21 at 1:20 P.M. – One time dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 given at
this time. The resident’s pain level is still 10 out of 10;
– 1/22 at 4:37 P.M. – Spoke to [MEDICAL TREATMENT] nurse regarding resident’s progress at
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 13 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 13)
[MEDICAL TREATMENT]. Nurse explained even when the resident attends [MEDICAL TREATMENT]
sessions, he/she still requests to come off the pump early. Nurse also informed this
writer the resident would be following up with the vascular physician regarding pain in
arm, nurse believes it has something to do with the [MEDICAL TREATMENT] assess;
– 1/23 at 6:46 P.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order;
– 1/23 at 7:22 P.M. – [MEDICATION NAME] 75 mg Med is n/a;
– 1/24 at 5:10 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense,
pharmacy fixing problem;
– 1/24 at 6:33 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense,
pharmacy fixing problem;
– 1/24 at 8:21 A.M. – Resident is refusing to go to [MEDICAL TREATMENT] this am;
– 1/24 at 2:45 P.M. – Placed call to physician’s office and notified someone from the
office the resident was out of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. The person
stated he/she would notify the physician. Oncoming nurse made aware;
– 1/25 5:12 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication did not
dispense. Pharmacy fixing problem. Day shift to follow up;
– 1/25/2019 at 6:39 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
did not dispense. Pharmacy working to fix problem;
– 1/25 at 11:52 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
unavailable. Placed call to the physician and spoke with somebody who stated he/she would
notify physician to return call to facility;
– 1/25 at 1:39 P.M. [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication not
available. MD aware. NO given, see MAR.
– 1/25 at 2:58 P.M. – Placed call to pharmacy regarding [MEDICATION NAME]-[MEDICATION
NAME], spoke with pharmacist. Pharmacist stated that he will contact the physician to
obtain emergency pain medication order for the resident and will return call to facility.
Awaiting call from pharmacist. Will notify oncoming nurse;
– 1/26 at 4:30 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on
order;
– 1/26 at 5:21 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on
order;
– 1/27 at 6:03 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A;
– 1/27 at 6:04 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A;
– 1/27 at 10:25 P.M. – [MEDICATION NAME] 75 mg Medication has not arrived. Not available
in E-KIT (emergency supply of medications) or (automated medication dispensing system).;
– 1/28 at 9:40 A.M. – Spoke with [MEDICAL TREATMENT] nurse today and she states on
Saturday (1/26/19) the resident requested to be removed from pump early and began yelling.
She explained the resident was upset he/she arrived to the [MEDICAL TREATMENT] treatment
late and used that as a reason to stop to session early;
– 1/28/19 at 11:36 P.M. – [MEDICATION NAME] HCL 50 mg Medication not given. (Onsite
medication dispensing) machine malfunctioning. Medication not dispensing. Staff unable to
properly fix machine;
– 1/29 at 5:08 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Unable to
dispense. Pharmacy called to fix problem;
– 1/29 at 7:10 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 mg Medication not
dispensing. Pharmacy fixing problem;
– 1/30 at 9:39 P.M. – [MEDICATION NAME] 75 mg Medication not available.
– 1/31 at 9:19 A.M. – The resident refused [MEDICAL TREATMENT] today. The resident said
he/she is tired of it and doesn’t need it;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 14 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 14)
Review showed staff only contacted the physician four times to notify him/her medications
were not available for the resident. Review showed 34 dosages of pain medication was not
given for (MONTH) 2019.
Review on 2/12/19 of the resident’s MAR and TAR, dated (MONTH) 2019, showed the following:

– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 on 2/6, 2/9, three times on 2/10, three times on 2/11 and
two times on 2/12. In addition, staff did not document the administration of the
medication and left the box blank/without a code once on 2/10. Staff did not document the
administration of this medication a total of 11 times;
– Staff documented the resident had pain on 2/1, 2/2, 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/10,
2/11 and 2/12 (11 out of a possible 12 days).
Review of the resident’s progress notes for (MONTH) 2019 showed staff documented the
following:
– 2/6 at 6:30 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Meds on order;
– 2/9 at 6:00 P.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication isn’t
available;
– 2/10 at 2:26 A.M. – Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME]
was not given;
– 2/10 at 6:12 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication n/a;
– 2/10 at 6:27 A.M. – Resident having pain at a number 7 on a scale 1-10;
– 2/10 at 11:11 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication isn’t
available;
– 2/11 at 3:35 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Med N/A;
– 2/11 at 3:35 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A;
– 2/11 at 5:31 A.M. – Resident pain at a 7 on a 1-10 pain scale;
– 2/11 at 6:25 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med n/a;
– 2/11 at 12:41 P.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
unavailable at this time;
– 2/12 at 4:53 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
reordered;
– 2/12 at 5:03 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
reordered;
– 2/12 at 8:27 A.M. – Resident refuses to attend [MEDICAL TREATMENT] today. Resident
states that he is having vomiting episodes with nausea. Resident observed dry heaving with
no stomach contents being emptied, just spitting in basin. Anti-nausea medication given to
resident. Physician notified of resident’s noncompliance with [MEDICAL TREATMENT]
treatment, nausea and vomiting;
– 2/12 at 5:11 P.M. – The resident is is bed and has complaints of fever and chills, no
sweating observed. The resident reports that he/she has generalized pain as well as pain
in stomach (cramping) and rates pain 10/10. Blood pressure 148/109, heart rate 97,
respirations 20, temperature 99.8, and oxygen saturation 98% on 2 liters of oxygen.
Physician notified that the resident missed [MEDICAL TREATMENT] treatment today. Received
an order to send the resident to the hospital for evaluation and treatment. Resident given
[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg for pain, medication somewhat effective. The
resident reports pain at 6/10 after administration. Ambulance in route.
Review showed staff did not did not document they notified the physician of the
[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg being unavailable.
During an attempted interview on 2/11/19 at 5:06 P.M., the resident yelled at the surveyor

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 15 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 15)
to leave him/her alone.
Observation on 2/12/19 at 5:15 P.M. showed the resident lay in bed on his/her back. The
resident raised his/her hands in the air and said in a loud voice Please Lord, just take
me.
During an interview on 2/14/19 at 10:11 A.M., the Director of Nurses (DON) said the
pharmacy the facility uses is in Indiana and they have used them for about a year. They
have an onsite medication dispensing machine that dispenses some of the medications. They
have had issues with the pharmacy providing them medications.
During an interview on 2/14/19 at 1:30 P.M., Certified Medication Technician (CMT) B said
the following:
– If staff do not document the administration of a scheduled medication on the MAR or TAR
then they are supposed to document why the medication was not given.
– The pharmacy they currently use is in the state of Indiana. They have to call that
pharmacy frequently and let them know they are out of medications. The pharmacy tells them
the medicines are ordered but they don’t come in. Whenever a medication is not available
he/she notifies the DON or administrator.
During an interview on 2/14/19 at 5:15 P.M., Licensed Practical Nurse (LPN) A said the
following:
– The resident gets scheduled [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg ever six hours
for severe pain;
– Staff have repeatedly tried to get this pain medication for the resident.
– When a medication is not available, staff should notify the resident’s physician and the
pharmacy. When staff contact the pharmacy or physician about a medication not being
available, they should document this in a progress note.
During an interview on 2/14/19 at 5:15 P.M., the Assistant Director of Nursing (ADON) said
the following:
– He expects staff to provide non pharmacological interventions for pain when a residents
pain medication is not available;
– Staff should notify the physician when a medication is not available and document this
in a progress note along with any new orders the physician gives for the resident;
– If a resident’s pain medication was unavailable and the resident’s pain was unbearable,
then they would send they resident to the hospital.
During an interview on 2/14/19 at 7:00 P.M., the MDS Coordinator said pain should be
addressed on the resident’s care plan.
During an interview on 2/14/19 at 7:30 P.M., the DON said the following:
– The resident frequently complains of pain. The resident has a hernia that causes pain.
– Pain should be addressed on the resident’s care plan;
– She is not aware if any staff asked a physician for an alternative pain medication for
the resident. They had a different dose of the [MEDICATION NAME]-[MEDICATION NAME]
available in the Ekit, it was a mater of the nurses not checking the Ekit.
– If a medication is not available staff should notify the physician and document this in
a progress note along with any alternative orders the physician gave. If it is more than a
one time thing that the medication is not available then they should get an order from the
physician for the medication to be held and see if the physician wants any alternative
medications ordered;
– If a medication is not given, staff should document why it was not given in a progress
note;
– She is unsure what staff mean when they document N/A. To her, that would mean not
applicable, but it does not make sense to put this for a scheduled medication. She is
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 16 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 16)
unsure if staff mean the medication was not available when they documented N/A in the
progress notes.
– Staff are always calling the pharmacy about medications not being available;
– If staff do not document they gave a medication then it is considered not given because
she can not prove they gave it.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to obtain
informed consent for the use of side rails for four residents (Residents #1, #35, #51 and
#64) with side rails. The facility census was 71.
1. Review of Resident #64’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 1/12/19, showed staff assessed the resident as:
-Dependent on staff assistance for bed mobility, transfers, locomotion on and off the
unit, dressing, and toilet use;
-Did not walk.
Review of the resident’s care plan related to the resident’s activities of daily living
(ADLs), revised 5/16/17, showed the resident has a self-care deficit and is dependent on
staff for completion of his/her ADLs. The plan directed staff to raise one-quarter side
rails on both sides per physician’s orders [REDACTED].
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s medical record showed staff did not obtain an informed consent
signed by the resident and/or resident representative for the use of side rails.
Observation on 2/12/19 at 5:22 P.M., showed the resident lay in bed with three one-quarter
side rails in the raised position.
Observation on 2/14/19 at 9:43 A.M., showed the resident sat upright in bed with three
one-quarter side rails in the raised position.
2. Review of Resident #35’s MDS, dated [DATE], showed the staff assessed the resident as
follows:
-Requires extensive assistance with dressing from staff;
-Dependent upon staff for assistance with bed mobility and transfers;
-Uses a wheelchair for mobility;
-Dementia diagnosis;
-[MEDICAL CONDITION] (one-sided weakness) diagnosis.
Review of the resident’s comprehensive care plan, updated on 7/26/17, directed staff to
place the quarter side rails up on both sides of the bed for positioning.
Review of the physician’s orders [REDACTED].
Review of the resident’s side rail assessment, dated dated 12/15/18, showed staff
documented the resident had side rails for positioning. Further review showed staff did
not require a signature for the consent and acknowledgement of the risks that can be
involved with the use of side rails.
Observation on 2/12/18 at 9:11 A.M., showed the resident sat up in bed with both quarter

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 17 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
side rails raised.
Observation on 2/13/18 at 3:00 P.M., showed the resident in bed with both quarter side
rails raised.
4. Review of Resident #1’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively intact;
-Requires limited assistance from one staff person for bed mobility, transfers, walking,
and personal hygiene;
-Requires extensive assistance from one staff person for toilet use.
Review of the resident’s current care plan directed staff to use two side rails and a
trapeze for bed mobility.
Review of the current Physician order [REDACTED].
Review of the resident’s medical record showed staff did not obtain an informed consent
signed by the resident and/or resident representative for the use of side rails.
Observation on 2/11/19 at 2:59 P.M., showed the resident in his/her bed with two side
rails in the raised position.
Observation on 2/14/19 at 9:21 A.M., showed the resident in his/her bed with two side
rails in the raised position.
During an interview on 2/14/19 at 9:21 A.M., the resident said he/she is able to operate
the side rails and tells staff to make sure they are up.
5. During an interview on 2/14/19 at 11:41 A.M., the MDS Coordinator said she is
responsible for completing the quarterly side rail assessments and the nurse completes the
side rail assessment upon admission. Further, the MDS Coordinator said she did not think
it was a requirement to get a signature for consent to use side rails.
3. Review of Resident #51’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Moderate cognitive impairment;
-Required limited assistance from one staff person for bed mobility, transfers, toilet use
and personal hygiene;
-Did not walk.
Review of the current Physician order [REDACTED].
Review of the resident’s current care plan, initiated 8/11/16, showed staff documented the
resident had a quarter side rail on left side of the bed that enabled him/her to go from
supine to sitting and assisted the resident with bed mobility and transfers.
Review of the resident’s medical record showed staff did not obtain an informed consent
signed by the resident and/or resident representative for the use of side rails.
Observation on 2/13/19 at 10:00 A.M., showed the resident in his/her bed with a quarter
side rail on each side of the resident’s bed. The left side rail was in the down position
and the right side rail was in the up position.
Observation on 2/14/19 at 1:20 P.M., showed the resident in his/her bed with a quarter
side rail on each side of the resident’s bed. The left side rail was in the down position
and the right side rail was in the up position.

F 0755

Level of harm – Actual harm

Residents Affected – Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 18 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 18)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to consistently
provide several routine medications (including an anticoagulant, a medication for elevated
potassium levels, a medication for high blood pressure and three different pain
medications) for one resident (Resident #16) which resulted in elevated blood pressure and
increased pain. Staff also failed to consistently provide multiple medications per
physician’s orders [REDACTED].#173), which included the resident’s antibiotics,
antianxiety, anticoagulant, muscle relaxants, and two different pain medications. The
facility census was 71.
1. Review of the chart codes on the Medication Administration Record (MAR) and Treatment
Administration Record (TAR) for the facility showed if a medication was not administered,
staff were to document one of the following:
– 1 = Absent from home without meds;
– 2 = Drug Refused;
– 3 = Absent from home with meds;
– 4 = Vitals Outside of Parameters for Administration;
– 5 = Hold/See Progress Notes;
– 6 = hospitalized ;
– 7 = Sleeping;
– 8 = Nauseated/Vomiting;
– 9 = Other/See Progress Notes.
2. Review of the American Heart Association High Blood Pressure Guidelines showed the
following:
– Normal: Less than 120/80 mm Hg;
– Elevated: Systolic between 120-129 and diastolic less than 80;
– Stage 1: Systolic between 130-139 or diastolic between 80-89;
– Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
– Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing
prompt changes in medication if there are no other indications of problems, or immediate
hospitalization if there are signs of organ damage.
Review of the Resident #16’s Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 11/20/18, showed staff assessed the resident as:
– Cognitively intact;
– diagnosed with [REDACTED].
– Received an anticoagulant seven out of the last seven days;
– Received an opioid seven out of the last seven days;
– Received [MEDICAL TREATMENT];
– Received scheduled pain medication;
– Received PRN (as needed) pain medication;
– Had occasional pain in the past five days.
Review of the resident’s care plan, initiated 8/14/18, showed staff documented the
following:
– The resident takes an anticoagulant because he/she has a history of a stroke. Staff were
directed to administer the anticoagulant as ordered by the physician;
– The resident receives [MEDICAL TREATMENT] three times per week. Staff were directed to
encourage the resident to go to scheduled [MEDICAL TREATMENT] appointments and work with
the resident to relieve discomfort for side effects of the disease and treatment
(cramping, headaches, fatigue, itching);
– The resident had behaviors of refusing medications, refusing [MEDICAL TREATMENT] and
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 19 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 19)
being resistive to care; the resident’s overall demeanor is angry and grumpy. Staff were
directed to observe behavioral episodes and attempt to determine underlying cause and
remove hindrance if possible.
Review of the resident’s MAR, dated (MONTH) 2019, showed the following:
– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 on 12/3, 12/4, twice on 12/8, 12/11, 12/13, 12/14, and
12/17 (a total of eight times);
– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 on 12/3 and 12/10 (a total of two times). The order was
discontinued on 12/21/18.;
– An order (dated 12/21/18) for Calcium Acetate 667 mg to be given by mouth with meals for
[MEDICAL CONDITION] (end stage [MEDICAL CONDITION]). Staff did not document the
administration of the medication and instead documented a code of 9 on 12/23, twice on
12/25 and 12/26 (a total of four times);
– An order (dated 12/4/18) for [MEDICATION NAME] 60 mg to be given by mouth two times a
day for high blood pressure. Staff did not document the administration of the medication
and instead documented a code of 9 twice on 12/8, on 12/9, 12/10, twice on 12/11, twice on
12/12, 12/13, 12/14, twice on 12/15, 12/16, twice on 12/17, 12/18 and 12/20 (a total of 17
times). The order was discontinued on 12/20/18. Blood pressure readings were documented
including elevated readings of 151/ 85 and 146/82 on 12/8, 152/86 and 164/70 on 12/9,
160/88 on 12/10, 132/78 and 148/68 on 12/11, 173/150 on 12/12, 157/93 and 160/97 on 12/14,
166/73 and 148/79 on 12/15, 140/40 and 132/58 on 12/16, 158/93 on 12/17, 153/59 and 146/76
on 12/18 and 165/77 on 12/19.
Review of the resident’s progress notes for (MONTH) (YEAR) showed staff documented the
following:
– 12/3 at 6:10 P.M. – Calcium Acetate is on order;
– 12/3 at 6:58 P.M. – Apixaban is out of stock;
– 12/4 at 5:55 P.M. – Apixaban on order;
– 12/8 at 10:17 A.M. – Staff did not document why the Apixaban was not given;
– 12/8 at 10:19 A.M. – Staff did not document why the [MEDICATION NAME] was not given;
– 12/8 at 7:57 P.M. – Apixaban on order;
– 12/8 at 7:57 P.M. – [MEDICATION NAME] on order;
– 12/9 at 6:36 P.M. – [MEDICATION NAME] on order;
– 12/10 at 10:01 – Calcium Acetate reordered from pharmacy;
– 12/10 at 5:17 P.M. – [MEDICATION NAME] not here;
– 12/11 at 11:54 A.M. – [MEDICATION NAME] on order;
– 12/11 at 7:18 P.M. – Apixaban on order;
– 12/11 at 7:20 P.M. – [MEDICATION NAME] on order;
– 12/12 at 11:03 A.M. – [MEDICATION NAME] not here;
– 12/12 at 4:53 P.M. – [MEDICATION NAME] not here;
– 12/13 at 5:04 P.M. – Apixaban on order;
– 12/13 at 5:04 P.M. – [MEDICATION NAME] on order;
– 12/14 at 5:33 P.M. – Apixaban on order;
– 12/14 at 5:33 P.M. – [MEDICATION NAME] on order;
– 12/15 at 9:35 A.M. – [MEDICATION NAME] on order;
– 12/15 at 6:31 P.M. – [MEDICATION NAME] on order;
– 12/16 at 11:10 A.M. – [MEDICATION NAME] not here;
– 12/17 at 11:38 A.M. – [MEDICATION NAME] medication was not given unavailable nurse is
aware;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 20 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 20)
– 12/17 4:07 P.M. – [MEDICATION NAME] med not in;
– 12/17 4:07 P.M. – Apixaban med not in;
– 12/18 at 2:15 P.M. – [MEDICATION NAME] on order;
– 12/20 at 3:02 P.M. – [MEDICATION NAME] not here;
– 12/23 at 11:15 A.M. – Staff did not document why the Calcium Acetate was not given;
– 12/25 at 9:29 A.M. – Calcium Acetate not available;
– 12/25 at 2:52 P.M. – Calcium Acetate not here;
– 12/26 at 10:15 A.M. – Calcium Acetate not here.
Review showed staff did not document they notified the physician of the Calcium Acetate,
[MEDICATION NAME] or Apixaban being unavailable.
Review of the resident’s MAR and TAR, dated (MONTH) 2019, showed the following:
– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 on 1/6, 1/13, 1/15, 1/19, 1/20 1/23, 1/27 and 1/30 (a total
of eight times);
– An order (dated 1/11/19) for [MEDICATION NAME] (an opioid pain medication) 50 mg
scheduled to be given by mouth every eight hours for pain. Staff did not document the
administration of the medication and instead documented a code of 9 twice on 1/12, 1/14,
1/20, 1/21 and 1/28 (a total of six times);
– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 twice on 1/1, twice on 1/2, 1/19, twice on 1/21, 1/23,
three times on 1/24, three times on 1/25, twice on 1/26, twice on 1/27 and twice on 1/29
(a total of 20 times);
– Staff documented the resident had pain every day this month (31 out of 31 days).
Review of the resident’s progress notes for (MONTH) 2019 showed staff documented the
following:
– 1/1 at 4:57 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/1 at 6:50 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/2 at 5:12 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/2 at 5:13 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Medication on order;
– 1/2 at 12:25 P.M. – [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg given. Spoke with
physician and made aware of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg not available.
Received a new order for [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg to be given by
mouth every six hours until the dosage of 5-325 mg comes in from pharmacy;
– 1/2 at 6:03 P.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg came in, order for
[MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg discontinued;
– 1/3 at 8:51 A.M. – Called [MEDICAL TREATMENT] to inform them the resident is refusing
[MEDICAL TREATMENT] treatment today. The resident is cursing and yelling;
– 1/6 at 10:06 P.M. – [MEDICATION NAME] 75 mg on order;
– 1/9 at 9:03 P.M. – [MEDICATION NAME] 75 mg medication not given on order;
– 1/12 at 5:20 A.M. – [MEDICATION NAME] HCL 50 mg New order. Awaiting delivery;
– 1/12 at 5:38 P.M. – [MEDICATION NAME] HCL 50 mg Medication isn’t available;
– 1/13 at 9:54 P.M. – Staff did not document why the [MEDICATION NAME] was not given;
– 1/14 at 6:49 A.M. – [MEDICATION NAME] HCL 50 mg Medication was n/a;
– 1/15 at 1:08 P.M. – Resident refused to go to [MEDICAL TREATMENT] today. Staff educated
the resident on the importance of keeping the scheduled [MEDICAL TREATMENT] treatments and
the resident started yelling and cursing. The resident continues to be verbally abusive
toward staff when asked if he/she needs any assistance with activities of daily living.
The resident continues to reject care at times;
– 1/15 at 7:44 P.M. – Staff did not document why the [MEDICATION NAME] was not given;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 21 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 21)
– 1/19 at 12:59 P.M. – Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME]
5-325 mg was not given;
– 1/19 at 8:48 P.M. – [MEDICATION NAME] 75 mg on order;
– 1/20 at 4:32 A.M. – Staff did not document why the [MEDICATION NAME] HCL 50 mg was not
given;
– 1/20 at 11:59 P.M. – [MEDICATION NAME] 75 mg on order;
– 1/21 at 4:04 A.M. – [MEDICATION NAME] HCL 50 mg Medication not available;
– 1/21 at 6:40 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order;
– 1/21 at 6:43 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Med N/a;
– 1/21 at 12:51 P.M. – Pain noted of 10/10 on pain scale. The resident is in bed and
states left arm in excruciating pain. Nurse tried to touch the resident’s left arm and the
resident yelled out in pain. Scheduled pain medication was given at 11:00 A.M.;
– 1/21 at 1:17 P.M. – Notified physician of the resident’s left arm pain. Received a new
order for an x-ray to left arm and for staff to give a dose of [MEDICATION
NAME]-[MEDICATION NAME] 5-325 now for pain.
– 1/21 at 1:20 P.M. – One time dose of [MEDICATION NAME]-[MEDICATION NAME] 5-325 given at
this time. The resident’s pain level is still 10 out of 10;
– 1/22 at 4:37 P.M. – Spoke to [MEDICAL TREATMENT] nurse regarding resident’s progress at
[MEDICAL TREATMENT]. Nurse explained even when the resident attends [MEDICAL TREATMENT]
sessions, he/she still requests to come off the pump early. Nurse also informed this
writer the resident would be following up with the vascular physician regarding pain in
arm, nurse believes it has something to do with the [MEDICAL TREATMENT] assess;
– 1/23 at 6:46 P.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg on order;
– 1/23 at 7:22 P.M. – [MEDICATION NAME] 75 mg Med is n/a;
– 1/24 at 5:10 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense,
pharmacy fixing problem;
– 1/24 at 6:33 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg Unable to dispense,
pharmacy fixing problem;
– 1/24 at 8:21 A.M. – Resident is refusing to go to [MEDICAL TREATMENT] this am;
– 1/24 at 2:45 P.M. – Placed call to physician’s office and notified someone from the
office the resident was out of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. The person
stated he/she would notify the physician. Oncoming nurse made aware;
– 1/25 5:12 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication did not
dispense. Pharmacy fixing problem. Day shift to follow up;
– 1/25/2019 at 6:39 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
did not dispense. Pharmacy working to fix problem;
– 1/25 at 11:52 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
unavailable. Placed call to the physician and spoke with somebody who stated he/she would
notify physician to return call to facility;
– 1/25 at 1:39 P.M. [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication not
available. MD aware. NO given, see MAR.
– 1/25 at 2:58 P.M. – Placed call to pharmacy regarding [MEDICATION NAME]-[MEDICATION
NAME], spoke with pharmacist. Pharmacist stated that he will contact the physician to
obtain emergency pain medication order for the resident and will return call to facility.
Awaiting call from pharmacist. Will notify oncoming nurse;
– 1/26 at 4:30 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on
order;
– 1/26 at 5:21 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication on
order;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 22 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 22)
– 1/27 at 6:03 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A;
– 1/27 at 6:04 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A;
– 1/27 at 10:25 P.M. – [MEDICATION NAME] 75 mg Medication has not arrived. Not available
in E-KIT (emergency supply of medications) or (automated medication dispensing system).;
– 1/28 at 9:40 A.M. – Spoke with [MEDICAL TREATMENT] nurse today and she states on
Saturday (1/26/19) the resident requested to be removed from pump early and began yelling.
She explained the resident was upset he/she arrived to the [MEDICAL TREATMENT] treatment
late and used that as a reason to stop to session early;
– 1/28/19 at 11:36 P.M. – [MEDICATION NAME] HCL 50 mg Medication not given. (Onsite
medication dispensing) machine malfunctioning. Medication not dispensing. Staff unable to
properly fix machine;
– 1/29 at 5:08 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Unable to
dispense. Pharmacy called to fix problem;
– 1/29 at 7:10 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 mg Medication not
dispensing. Pharmacy fixing problem;
– 1/30 at 9:39 P.M. – [MEDICATION NAME] 75 mg Medication not available.
– 1/31 at 9:19 A.M. – The resident refused [MEDICAL TREATMENT] today. The resident said
he/she is tired of it and doesn’t need it;
Review showed staff only contacted the physician four times to notify him/her medications
were not available for the resident. Review showed 34 dosages of pain medication was not
given for (MONTH) 2019.
Review on 2/12/19 of the resident’s MAR and TAR, dated (MONTH) 2019, showed the following:

– an order for [REDACTED]. Staff did not document the administration of the medication and
instead documented a code of 9 on 2/6, 2/9, three times on 2/10, three times on 2/11 and
two times on 2/12. In addition, staff did not document the administration of the
medication and left the box blank/without a code once on 2/10. Staff did not document the
administration of this medication a total of 11 times;
– Staff documented the resident had pain on 2/1, 2/2, 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/10,
2/11 and 2/12 (11 out of a possible 12 days).
Review of the resident’s progress notes for (MONTH) 2019 showed staff documented the
following:
– 2/6 at 6:30 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Meds on order;
– 2/9 at 6:00 P.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication isn’t
available;
– 2/10 at 2:26 A.M. – Staff did not document why the [MEDICATION NAME]-[MEDICATION NAME]
was not given;
– 2/10 at 6:12 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication n/a;
– 2/10 at 6:27 A.M. – Resident having pain at a number 7 on a scale 1-10;
– 2/10 at 11:11 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Medication isn’t
available;
– 2/11 at 3:35 A.M. – [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG Med N/A;
– 2/11 at 3:35 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med N/A;
– 2/11 at 5:31 A.M. – Resident pain at a 7 on a 1-10 pain scale;
– 2/11 at 6:25 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Med n/a;
– 2/11 at 12:41 P.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
unavailable at this time. Medication is not in (the onsite medication dispensing) machine
for dispensing;
– 2/12 at 4:53 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 23 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 23)
reordered;
– 2/12 at 5:03 A.M. – [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Medication
reordered;
– 2/12 at 8:27 A.M. – Resident refuses to attend [MEDICAL TREATMENT] today. Resident
states that he is having vomiting episodes with nausea. Resident observed dry heaving with
no stomach contents being emptied, just spitting in basin. Anti-nausea medication given to
resident. Physician notified of resident’s noncompliance with [MEDICAL TREATMENT]
treatment, nausea and vomiting;
– 2/12 at 5:11 P.M. – The resident is is bed and has complaints of fever and chills, no
sweating observed. The resident reports that he/she has generalized pain as well as pain
in stomach (cramping) and rates pain 10/10. Blood pressure 148/109, heart rate 97,
respirations 20, temperature 99.8, and oxygen saturation 98% on 2 liters of oxygen.
Physician notified that the resident missed [MEDICAL TREATMENT] treatment today. Received
an order to send the resident to the hospital for evaluation and treatment. Resident given
[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg for pain, medication somewhat effective. The
resident reports pain at 6/10 after administration. Ambulance in route.
Review showed staff did not did not document they notified the physician of the
[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg being unavailable.
During an attempted interview on 2/11/19 at 5:06 P.M., the resident yelled at the surveyor
to leave him/her alone.
Observation on 2/12/19 at 5:15 P.M., showed the resident lay in bed on his/her back. The
resident raised his/her hands in the air and said in a loud voice Please Lord, just take
me.
During an interview on 2/14/19 at 5:15 P.M., Licensed Practical Nurse (LPN) A said the
following:
– The resident gets scheduled [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg ever six hours
for severe pain;
– Staff have repeatedly tried to get this pain medication for the resident.
During an interview on 2/14/19 at 7:30 P.M., the Director of Nursing (DON) said the
following:
– The resident frequently complains of pain. The resident has a hernia that causes pain.
– Pain should be addressed on the resident’s care plan;
– She is not aware if any staff asked a physician for an alternative pain medication for
the resident. They had a different dose of the [MEDICATION NAME]-[MEDICATION NAME]
available in the Ekit, it was a mater of the nurses not checking the Ekit.
3. Review of Resident #173’s medical record showed the resident was admitted to the
facility on [DATE].
Review of the resident’s TAR, dated (MONTH) 2019, showed the following:
-an order for [REDACTED]. Staff did not document administration of the medication on 2/9
and 2/10. Additionally, staff did not document administration of the medication and
instead documented a code of 9 on 2/12/19.
-an order for [REDACTED]. Staff did not document administration of the medication on 2/9
and 2/10. Additionally, staff did not document administration of the medication and
instead documented a code of 9 on 2/12/19.
-an order for [REDACTED]. Staff did not document administration and instead documented a
code of 9 on 2/9 (am dose), 2/10 (am and pm doses), and 2/11 (am dose). Additionally,
staff did not document administration of the medication on 2/9 (pm dose).
-an order for [REDACTED]. Staff did not document administration of the medication on 2/11.
-an order for [REDACTED]. Staff did not document administration of the medication on 2/9
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 24 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 24)
(pm dose) and 2/10 (pm dose).
-an order for [REDACTED]. Staff did not document administration and instead documented a
code of 9 on 2/9 (am dose). Additionally, staff did not document administration of the
medication on 2/9 (pm dose) and 2/11 (pm dose).
-an order for [REDACTED]. Staff did not document administration of the medication on 2/9
(pm dose).
-an order for [REDACTED]. Staff did not document administration of the medication on 2/9
(5:00 pm dose).
-An order [MEDICATION NAME] HFA aerosol solution (opens up the airways in the lungs) 17
mcg/act, one puff via [MEDICAL CONDITION] three times daily. Staff did not document
administration and instead documented a code of 9 on 2/9 (noon dose). Additionally, staff
did not document administration of the medication on 2/9 (pm dose) and 2/11 (pm dose).
-an order for [REDACTED]. Staff did not document administration and instead documented a
code of 9 on 2/9 (1:00 am dose), 2/10 (5:00 pm dose) 2/11 (1:00 am dose and 9:00 am dose),
and 2/12 (1:00 am dose). Additionally, staff did not document administration of the
medication on 2/9 (5:00 pm dose), 2/10 (1:00 am dose), and 2/11 (5:00 pm dose).
-an order for [REDACTED]. Staff did not document administration of the medication on 2/9
(pm dose).
-an order for [REDACTED]. Staff did not document administration on 2/10 (bedtime dose).
-an order for [REDACTED]. Staff did not document administration and instead documented a
code of 9 on 2/9 (midnight dose, 4:00 am dose, 8:00 am dose and noon dose), 2/10 (4:00 pm
dose), 2/11 (midnight dose, 4:00 am dose, 8:00 am dose and noon dose), 2/12 (midnight dose
and 4:00 am dose), and 2/13 (midnight dose and noon dose). Staff did not document
administration of the medication on 2/9 (4:00 pm dose), and 2/10 (midnight dose, 4:00 am
dose and 8:00 pm dose).
-an order for [REDACTED]. Staff did not document administration and instead documented a
code of 9 on 2/9 and 2/12.
Review of the resident’s progress notes from his/her admission date of [DATE]-2/14/19,
showed the following:
-On 2/14/19 at 15:43, staff documented they placed a call to the resident’s physician
regarding the resident’s [MEDICATION NAME] script. Staff documented the physician’s office
requested a faxed face sheet and medication list, which staff faxed at that time.
-Staff did not otherwise document why the above medications were not administered.
During an interview on 2/13/19 at 9:00 A.M., the resident said he/she was admitted on
Friday (five days prior) and said staff have had trouble getting all of his/her
medications in to the facility.
During an interview on 2/14/19 at 9:11 A.M., the resident said he/she believed he/she
received all of his medications that morning except they may still be waiting on his/her
pain patch. The resident was unsure as to whether staff were substituting something for
the patch. He/she said he/she had pain in his/her shoulders which seemed to be a little
worse without the pain patch.
During an interview on 2/14/19 at 11:31 A.M., LPN E said the facility had now received all
of the resident’s medications except for his/her [MEDICATION NAME]es. The LPN said the
resident came from the hospital without any scripts. The LPN said he/she had to call the
pharmacy when he/she arrived to the facility on Monday morning to get the resident’s
medications. The nurse practitioner signed the scripts and staff got them to the pharmacy
and the facility received the resident’s [MEDICATION NAME] and [MEDICATION NAME]
([MEDICATION NAME]-[MEDICATION NAME]) on Tuesday (the 12th). The LPN said the nurse
practitioner couldn’t sign the script for the [MEDICATION NAME], so the LPN has called the
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 25 of 27
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 25)
resident’s physician and asked to get a script for the resident’s [MEDICATION NAME]. The
LPN said he/she needed to call the pharmacy to see if the resident’s physician had signed
a script. The LPN said the facility’s emergency kit of medication did not have [MEDICATION
NAME] and the resident had exhausted the facility’s supply of [MEDICATION NAME]. The LPN
said he/she was unsure if anyone tried to get any of the resident’s scripts prior to
Monday. The LPN said the resident’s routine medications came out of the onsite medication
dispensing system.
During an interview on 2/14/19 2:58 P.M., the administrator said they had some issues with
the resident’s scripts. The resident was admitted over the weekend from the hospital. The
administrator said staff try to get the hospital to send hard scripts, but that doesn’t
always work out.
4. During an interview on 2/14/19 at 10:11 A.M., the DON said the pharmacy the facility
uses is in Indiana and they have used them for about a year. They have a onsite medication
dispensing machine that dispenses some of the medications. They have had issues with the
pharmacy providing them medications.
5. During an interview on 2/14/19 at 1:30 P.M., Certified Medication Technician (CMT) B
said the following:
– If staff do not document the administration of a scheduled medication on the MAR or TAR
then they are supposed to document why the medication was not given;
– The pharmacy they currently use is in the state of Indiana. They have to call that
pharmacy frequently and let them know they are out of medications. The pharmacy tells them
the medicines are ordered but they don’t come in. Whenever a medication is not available
he/she notifies the DON or administrator.
6. During an interview on 2/14/19 at 5:15 P.M., LPN A said when a medication is not
available, staff should notify the resident’s physician and the pharmacy. When staff
contact the pharmacy or physician about a medication not being available, they should
document this in a progress note.
7. During an interview on 2/14/19 at 5:15 P.M., the Assistant Director of Nursing (ADON)
said the following:
– He expects staff to provide non-pharmacological interventions for pain when a residents
pain medication is not available;
– Staff should notify the physician when a medication is not available and document this
in a progress note along with any new orders the physician gives for the resident;
– If a resident’s pain medication was unavailable and the resident’s pain was unbearable,
then they would send they resident to the hospital.
8. During an interview on 2/14/19 at 7:30 P.M., the DON said the following:
– If a medication is not available, staff should notify the physician and document this in
a progress note along with any alternative orders the physician gave. If it is more than a
one time thing that the medication is not available, then they should get an order from
the physician for the medication to be held and see if the physician wants any alternative
medications ordered;
– If a medication is not given, staff should document why it was not given in a progress
note;
– She is unsure what staff mean when they document N/A. To her, that would mean not
applicable, but it does not make sense to put this for a scheduled medication. She is
unsure if staff meant the medication was not available when they documented N/A in the
progress notes;
– Staff are always calling the pharmacy about medications not being available;
– If staff do not document they gave a medication, then it is considered not given because
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 26 of 27
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265402

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RANCHO MANOR HEALTHCARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

615 RANCHO LANE
FLORISSANT, MO 63031

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 26)
she can not prove they gave it.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265402If continuation sheet
Page 27 of 27
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