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: 0
Date: Aug 26, 2021
Visit Reason
Annual survey inspection of Park Manor Health and Rehabilitation, LLC to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 21, 2019
Visit Reason
The inspection was conducted based on complaints alleging bed bug infestations and concerns about infection control, food safety, medication storage, facility maintenance, and quality assurance oversight.
Complaint Details
The investigation was triggered by complaints received on 5/14/19 and 6/07/19 alleging bed bug infestations in resident rooms and inadequate treatment by the facility. Additional complaints involved infection control and maintenance issues.
Findings
The facility failed to properly secure controlled medication storage, maintain food safety standards, implement effective pest control and bed bug eradication measures, ensure infection control during medication administration, and maintain the physical environment. The Quality Assurance Performance Improvement (QAPI) plan was not effectively implemented, leading to the spread of bed bugs. Several maintenance issues were also noted in resident rooms.
Deficiencies (7)
Failed to ensure the controlled box containing narcotics was permanently affixed inside the refrigerator.
Failed to ensure food was consistently labeled with open and use-by dates, reheated to proper temperatures, and residents' refrigerators were clean and properly labeled.
Failed to provide necessary oversight to ensure a Quality Assurance Performance Improvement plan was implemented after identification of bed bugs, resulting in spread of infestation.
Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action related to bed bug infestation.
Failed to ensure infection prevention and control during medication administration; multi-use items were placed on unclean surfaces and returned to medication cart without cleaning.
Failed to maintain resident rooms free of chipped paint, splintered plywood, broken fixtures, and damaged furniture, creating potential hazards.
Failed to implement effective pest control measures to prevent and control bed bug infestations, including proper laundering and cleaning protocols.
Report Facts
Residents affected by bed bugs: 4
Resident rooms with bed bugs: 6
Residents affected by food safety issues: 130
Residents affected by medication storage deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Administrator | Failed to ensure QAPI plan was implemented for bed bug control; unaware of protocol breaches. |
| EI #2 | Director of Nursing (DON) | Confirmed medication storage box was not securely affixed; acknowledged bed bug protocol breaches. |
| EI #3 | Director of Maintenance | Observed maintenance deficiencies and acknowledged inadequate bed bug control procedures. |
| EI #4 | Housekeeping/Laundry Director | Acknowledged failure to follow bed bug cleaning and laundering protocols. |
| EI #11 | Licensed Practical Nurse (LPN) | Observed placing multi-use items on unclean surfaces during medication administration. |
| EI #13 | Certified Nursing Assistant (CNA) | Reported bed bug sightings and improper resident handling during bed bug control. |
| EI #14 | Certified Nursing Assistant (CNA) | Reported bed bug sightings and pest control information. |
| EI #2 | Registered Nurse (RN)/Director of Nursing | Interviewed about bed bug spread and infection control issues. |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 4
Date: Jul 19, 2018
Visit Reason
The inspection was conducted to investigate complaints related to failure in completing a required Level II PASARR screening for a resident transitioning from short term to long term care, dietary staff hygiene and food safety practices, and infection control breaches during medication administration.
Complaint Details
The visit was complaint-related, triggered by concerns about failure to complete required PASARR screening, dietary hygiene violations, and infection control breaches during medication administration. Substantiation status is not explicitly stated.
Findings
The facility failed to complete a required Level II PASARR screening for a resident transitioning to long term care, dietary staff failed to follow proper hand hygiene and food safety protocols including handling items dropped on the floor and wearing aprons improperly, and licensed nursing staff failed to follow hand hygiene and medication administration policies, risking cross contamination and infection.
Deficiencies (4)
Failed to ensure a Level II PASARR screening was completed for a resident transitioning from short term to long term care.
Dietary staff failed to wash hands after picking up items from the floor, entered kitchen with aprons on, and used bowls with water droplets, risking cross contamination.
Grease receptacle outside kitchen had accumulation of grease-like substance, posing risk of attracting flies and bugs.
Licensed nursing staff failed to follow hand hygiene protocols during medication administration and gastrostomy tube checks, including not washing hands after checking tube placement and handling medication tablets improperly.
Report Facts
Residents affected: 1
Residents affected: 119
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #4 | Facility Social Worker | Interviewed regarding missed Level II PASARR screening |
| EI #6 | Dietary Employee | Observed dropping lid on floor and failing to wash hands |
| EI #5 | Dietary Employee | Observed entering kitchen with apron on |
| EI #7 | Dietary Manager | Interviewed about dietary hygiene policies and observations |
| EI #3 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene and medication administration |
| EI #2 | Registered Nurse | Observed and interviewed regarding medication administration and hand hygiene |
| EI #1 | Director Nursing, Infection Control Nurse | Interviewed about infection control policies and staff practices |
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