Rolla Presbyterian Manor

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff also failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. These failures have the potential to affect all residents. The facility census was 19. 1. Review of the facility's Food Storage policy, revised January 2024, showed: -Food is stored immediately after receipt and maintained in a manner that prevents damage, spoilage, infestation and bacterial contamination; -All products are labeled and dated with the receiving date. Move old supplies to the front of the shelf to ensure rotation of products and place new supplies to the rear of the shelf; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to properly contain waste and refuge to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor waste containers remained covered when not in actual use. This failure has the potential to affect all facility occupants. The facility census was 19. 1. Review of the facility's Garbage policy, undated, showed: -Team members must handle garbage in a manner that will minimize contamination and prevent pests; -This procedure applies to all units and the manger/person in charge is responsible to ensure that the removal and disposal of garbage is handled properly to minimize contamination and prevent pests; -Ensure garbage containers have bags and the containers must be covered when not in use. Observations on 03/05/25 at 6:22 A.M., 6:42 A.M., 7:50 A.M. [...]

Inspectors wroteBased on record review and interview, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) when staff did not complete a discharge summary for resident (Resident #5), did not document a weight loss or injections received for one resident (Resident #6), failed to accurately document medication use for one resident (Resident #9), did not document a pressure injury for one resident (Resident #11), and failed to complete a significant change of status assessment (SCSA) for one resident (Resident #17) for hospice services. The facility census was 21. 1. Review of the facility's MDS Data Accuracy policy, dated [DATE], showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an accident free environment when staff failed to provide a safe mechanical transfer for two residents (Resident #6, and #17). Facility staff failed to store razors in a safe and effective manner in an unlocked shower room. The facility census was 21. 1. Review of the facility's Lifting and Transferring Residents policy, dated October 11, 2007, showed staff were directed as follows: -The facility will provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to prevent injury; -Staff is accountable for utilizing proper body mechanics, lifting techniques and resident safety. [...]

Inspectors wroteBased on observation, interview and record review, staff failed to maintain adequate infection control practices to prevent the transmission of infection when staff failed to use appropriate hand hygiene and perineal cleansing during provisions of personal care for three (Resident #14, #17, and #19) of three sampled residents. The facility census was 21. 1. Review of the facility's Hand Hygiene policy, revised September 7, 2022, showed when hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or body fluids, wash hands with soap and water. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 28. 1. Review of the facility's Hand Hygiene policy, dated 05/2018, showed Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Review showed the policy directed staff to wash their hands before and after handling contaminated items and after they remove gloves. Review showed the policy directed staff to not reuse or wash disposable gloves. Review also showed the policy directed the staff to use the following technique when performing hand hygiene using soap and water: -Wet hands with water; -Apply enough soap to cover all hand surfaces; [...]

Inspectors wroteBased on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for one resident (Resident #2) and failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #3, and #18). The facility census was 28. 1. Review of the facility's Psychoactive Psychopharmacological Medications policy showed the following: For the purposes of this policy, psychoactive medications includes antidepressants, anxiolytics, hypnotics, sedatives and antipsychotics. For any of these type of medications, gradual dose reductions and behavioral interventions will be done per physician orders, unless clinically contraindicated, in an effort to discontinue the medication or to reach the lowest effective dose. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide notice related to transfers of residents to the hospital to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) for five of four sampled residents (Resident #9, #11, #30, and #230). The facility census was 28. 1. Review of the facility's Admission, Transfer and Discharge Policy, revised 12/6/21, showed the policy did not include direction for staff to notify the ombudsman for resident discharges or transfers. Review of an email from the Ombudsman on 12/15/22 at 8:44 A.M., showed the Ombudsman wrote the facility does not send him/her monthly notifications of discharged or transferred residents. 2. Review of Resident #9's medical record showed the following: -Transferred to the hospital on 8/35/22; [...]