Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 4, 2024
Visit Reason
The inspection was conducted as part of a regulatory survey to assess compliance with healthcare and safety standards at Andalusia Manor nursing home.
Findings
The facility was found deficient in providing respiratory care as ordered for a resident, specifically oxygen was administered at incorrect flow rates. Additionally, food storage practices in the kitchen were inadequate, with improperly sealed, unlabeled, and outdated food items found in the walk-in cooler, posing potential harm to residents.
Deficiencies (2)
Failed to ensure Resident #33 received oxygen at the ordered two liters per minute on 01/02/2024 and 01/03/2024; oxygen was administered at three liters per minute instead.
Food stored in the walk-in cooler was not completely covered, sealed, or labeled properly, and outdated food was not discarded on 01/02/2024.
Report Facts
Residents affected: 1
Residents affected: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #9 | Interviewed regarding oxygen administration for Resident #33 | |
| Dietary Manager (DM) | Interviewed regarding food storage and labeling deficiencies |
Inspection Report
Census: 132
Deficiencies: 2
Date: Oct 17, 2019
Visit Reason
The inspection was conducted to assess compliance with respiratory care and food safety standards at Andalusia Manor.
Findings
The facility failed to ensure proper storage and dating of respiratory treatment masks for one resident, posing infection control risks. Additionally, 10 metal pans were found wet and stacked, which could lead to bacterial contamination affecting all residents receiving meals.
Deficiencies (2)
Failure to ensure Resident Identifier #220's breathing treatment mask was stored in a Ziploc bag and dated.
Failure to ensure 10 metal pans were not wet and stacked on a shelf, ready for use.
Report Facts
Residents affected: 1
Residents affected: 132
Number of pans: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding respiratory treatment mask storage and care for Resident #220 | |
| Registered Nurse (RN), Infection Control Specialist | Interviewed regarding treatment mask change frequency and infection control | |
| Certified Dietary Manager (CDM) | Observed wet metal pans and assisted in their removal | |
| Dietary Manager | Interviewed regarding wet metal pans and potential harm |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 12, 2018
Visit Reason
The inspection was conducted as a result of complaint investigations including medication administration errors, wound care deficiencies, tube feeding rate errors, and infection control concerns.
Complaint Details
The investigation was triggered by complaint #AL00035677 regarding medication administration errors involving a licensed nurse and CNA resulting in wrong resident medication administration.
Findings
The facility was found deficient in multiple areas including failure to accurately code hospice status in assessments, medication administration errors involving unlicensed staff giving medications, improper wound care practices leading to contamination risks, incorrect tube feeding rates, failure to ensure competency of nursing staff, food safety violations including improper hand hygiene and food temperature monitoring, and improper infection control practices during medication administration.
Deficiencies (7)
Failed to ensure Resident #112's Significant Change MDS assessment reflected hospice status.
Licensed nurse prepared medication and gave it to CNA who administered it to the wrong resident, resulting in medication error.
Failed to ensure licensed staff used proper wound care techniques including glove changes and avoiding contamination.
Tube feedings for Residents #83 and #8 were not administered at the correct physician ordered rates.
Licensed nurse gave prepared medication to CNA to administer, which was given to wrong resident.
Failed to ensure staff washed hands before putting on new gloves, took food temperatures properly, and served dry utensils.
Licensed staff removed gloves from uniform pocket and used them for medication administration, risking contamination.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse MDS/Care Plan Coordinator | Interviewed regarding failure to code hospice on MDS for Resident #112 | |
| EI #2 | Licensed Nurse | Prepared medication in Ensure and gave to CNA, resulting in medication error |
| EI #3 | Certified Nursing Assistant (CNA) | Administered medication to wrong resident due to nurse's error |
| EI #9 | Unit Registered Nurse | Interviewed about medication error incident |
| EI #1 | Director of Nursing | Interviewed about medication error and subsequent disciplinary actions |
| EI #4 | Licensed Practical Nurse | Observed performing improper wound care practices |
| EI #11 | Infection Control Nurse | Interviewed about wound care and glove use policies |
| EI #16 | Licensed Practical Nurse | Interviewed about tube feeding rates and responsibility |
| EI #14 | Dietary Assistant | Observed not washing hands before glove use in kitchen |
| EI #17 | Cook | Observed not taking all food temperatures properly |
| EI #12 | Licensed Practical Nurse | Observed removing gloves from uniform pocket and using for medication administration |
| EI #15 | Dietary Aide | Interviewed about wet utensils and trays on tray line |
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