Andalusia Manor

Inspectors wroteBased on observations, interviews, the facility's document Associate In-Service Record, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, the facility failed to ensure food stored in the walk-in cooler was completely covered, sealed, labeled properly, and outdated food was discarded on 01/02/2024 during the initial kitchen observation. This had the potential to affect 82 of 82 residents receiving food from the kitchen.

Inspectors wroteBased on observations, interview, resident record review, and review of a facility policy titled Oxygen Therapy, the facility failed to ensure Resident Identifier (RI) #33, one of one resident sampled for Respiratory Care, received oxygen (O2) at two liters per minute (2 l/m) as ordered by physician, on 01/02/2024 and 01/03/2024, two of three days of the survey.

Inspectors wroteBased on observation, interview, and a review of a facility policy titled,Manual Warewashing, the facility failed to ensure 10 metal pans were not wet and stacked on a shelf, ready for use. This was observed on 10/16/19, and had the potential to affect 132 of 132 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, Manual Warewashing with a revised date of 9/2017, revealed: . Procedures . 3. All serviceware and cookware will be air dried prior to storage . On 10/16/19 at 5:10 PM, the surveyor observed 10 pans stacked on a shelf wet with water. The surveyor, along with Employee Identifier (EI) #4, Certified Dietary Manager (CDM), observed the wetness of the pans. EI #4 began to remove the pans that were wet. A total of 10 pans were removed from the shelf. EI #3, Dietary Manager, was asked if the pans that were wet were supposed to be clean. [...]

Inspectors wroteBased on observations, interviews, record review and a review of a facility policy titled, OXYGEN THERAPY AEROSOL TREATMENT, the facility failed to ensure Resident Identifier (RI) #220's breathing treatment mask was stored in a Ziploc bag and the mask and the tubing was dated. This affected RI #220, one of two residents sampled with respiratory treatments. Findings Include: A review of a facility policy titled, OXYGEN THERAPY AEROSOL TREATMENT with no date, revealed: .7. Store nebulizer sets in plastic bag change weekly and as needed. 8. Change oxygen and nebulizer sets and bags weekly. Date when changed. RI #220 was admitted to the facility on [DATE] and re-admitted [DATE], with diagnoses of Chronic Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease. [...]

Inspectors wroteBased on observations, interviews and review of facility policies titled, Food Preparation, Service Line Checklist and Manual Warewashing, the facility failed to ensure: 1. staff washed hands before putting on a new pair of gloves; 2. the temperatures of all food items on the tray line were taken; and 3. spoons, forks and trays were not wet at the tray line. This was observed on 10/10/2018 and had the potential to affect 128 of 128 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Food Preparation with a revised date of 9/2017 revealed: .Procedures 1. All staff will practice proper hand washing techniques and glove use. On 10/10/2018 at 11:09 a.m., the surveyor observed (Employee Identifier) EI #14, dietary assistant, touch the trash can lid to put her gloves in the trash can. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident Identifier (RI) # 112's Significant Change Minimum Data Set (MDS) assessment, dated 9/4/18, reflected hospice. Findings Include: RI #112 was admitted to the facility on [DATE] with a diagnosis to include Alzheimer's disease with late onset. On 10/11/18 at 1:48 PM a review of RI #112's September 2018 Physician orders revealed, . Admit to . Hospice 8/29/18 . A review of RI #112's Significant Change MDS assessment, dated 9/4/18, did not indicated hospice service checked. On 10/11/18 at 2:00 PM, an interview was conducted Employee Identifier (EI) #10, Registered Nurse MDS/Care Plan Coordinator. EI #10 was asked if RI #112 was receiving hospice services. EI #10 replied, yes. EI #10 was asked when was RI #112 admitted to hospice. EI #10 replied, 8/29/18. EI #10 was asked if a Significant Change MDS was completed. [...]

Inspectors wroteBased on record review, interview and the review of a facility policy titled, Medication Administration, the facility failed to ensure a licensed nurse did not prepare medication for Resident Identifier (RI) # 73 and then give the medication to a Certified Nursing Assistant (CNA) to give to the resident. This practice resulted in the CNA accidentally giving the medication to another resident, RI # 175. This occurred on 4/26/18 and was cited as a result of the investigation of complaint # AL00035677. Findings Include: A review of an undated facility policy titled, MEDICATION ADMINISTRATION: revealed .POLICY : Medications are administered only by licensed nursing personnel . PROCEDURES: .11. Give the resident the medication . [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy titled, DRESSING CHANGE CLEAN, the facility failed to ensure licensed staff did not: 1. place the wound cleaner bottle on Resident Identifier (RI) #176 and RI #105's bed, then return the bottle to the treatment cart; 2. use the same gloves to clean the wounds and then place the treatment and clean dressing on RI #176 and RI #105 wounds and 3. remove a pen from her uniform pocket with soiled gloves and initial and date the outer dressing, then return the pen to her pocket and remove and use again on another resident. This was observed on 10/10/18 and affected RI #176 and RI #105, two of five residents identified by the facility with pressure ulcers. Findings Include: A review of an undated facility policy titled, DRESSING CHANGE CLEAN revealed .PROCEDURE: .2. Wash Hands 3. [...]

Inspectors wroteBased on observations, interview, record reviews and review of facility policy titled, Tube Feedings, the facility failed to ensure Resident Identifier (RI) # 83's and RI #8's tube feeding were running at the correct rates, as ordered by the physician for the tube feeding and the hourly water flush. This was observed on 10/11/2018 and affected two of two residents sampled who were receiving tube feedings Findings Include: A review of a facility policy, no date, titled, Tube Feedings revealed .POLICY: . A physician order specifying type of solution, amount, and frequency is required. PROCEDURE: . Pump Feeding . 4. set prescribed rate . 1) RI #83 was readmitted to the facility on [DATE] with diagnoses of anoxic brain damage and gastrostomy status. A review of RI #83's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/20/18, revealed: [...]

Inspectors wroteBased on record review, interview and review of the facility Job Description and Performance Standards Position Title Charge Nurse and Position Title Certified Nursing Assistant (CNA),the facility failed to ensure a licensed nurse did not give prepared medication to a CNA to give to a resident, which in turn was given to the wrong resident. This deficiency is cited as a result of the investigation of complaint # AL00035677, and affected two of two residents. Findings Include: A review of a facility JOB DESCRIPTION AND PERFORMANCE STANDARDS Charge Nurse revealed .1. Follow established standards of nursing practices and implement facility policies and procedures.18. Administer and document direct resident care, medications and treatments per physicians orders and accurately record all care provided. A review of an undated policy MEDICATION ADMINISTRATION revealed .POLICY: [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy titled, MEDICATION ADMINISTRATION, the facility failed to ensure a licensed staff did not remove gloves from her uniform pocket and put them on prior to administering medications by a gastrostomy tube for Resident Identifier (RI) #30. This was observed during medication administration on 10/10/18 and affected one of five nurses observed. Findings Include: A review of an undated facility policy titled, MEDICATION ADMINISTRATION revealed .PROCEDURES: 1. c. Clean gloves to be worn as appropriate when risk of contact with secretions/excretions blood or body fluids . RI #20 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include Gastrostomy status. A review of RI #20's October 2018 Physician Orders revealed . [...]