Based on interview, review of the facility's Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms and review of a facility policy titled, Drug destruction, the facility failed to ensure the Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms contained the two required signatures. This deficient practice affected September 2018, October 2018, January 2019 and August 2019, four of twelve months of Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms reviewed. Findings Include: A review of a facility policy titled, Drug destruction, dated 12/03/2018, revealed: . 5. A Non-Controlled Medication Destruction Record must be maintained for all non-controlled drugs destroyed . The following information shall be included on this record: . h. The signature of the consultant pharmacist destroying the medications; and i. The signature of the person(s) witnessing the destruction of the medications. Review of the CERTIFICATE OF INVENTORY AND DESTRUCTION forms for the Non-Controlled drugs, dated September 8, 2018, revealed seven sheets with one signature; September 9, 2018, revealed one sheet with one signature, October 14, 2018, revealed one sheet with one signature, January 1, 2019, revealed one sheet with one signature and August 25, 2019, revealed one sheet with one signature. On 10/03/2019 at 12:04 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Registered Nurse (RN) Assistant Director of Nursing (ADON). EI #1 was asked, when reviewing the Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms for the dates of January 1, 2019; August 25, 2019; September 8, 2018; September 9, 2018 and October 14, 2018, how many signatures were noted on the forms. EI #1 said one. EI #1 was asked how many signatures should be on the Non-Controlled CERTIFICATE OF INVENTORY AND DESTRUCTION forms. EI #1 said two. EI #1 was asked why was there only one signature on the CERTIFICATE OF INVENTORY AND DESTRUCTION forms. EI #1 said with the volume of papers, the sheets may not have been seen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication pass observation, staff interview, medical record review and a review of [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #5 followed physician's orders for Resident Identifier (RI) #31's order for Miralax. This deficient practice affected RI #31, one of four residents and EI #5, one of three nurses observed during medication administration. Findings Include: Review of [NAME] and Perry's, FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT V, CHAPTER 32, Foundations for Nursing Practice, Medication Administration, pages 626, 658 and 659, revealed: .Standards Standards are actions that ensure safe nursing practice . To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications . 2. The right dose . SKILL 32-1 ADMINISTERING ORAL MEDICATIONS . STEP . i. Stay until patient completely takes all medications by their prescribed route . RATIONALE . You are responsible for ensuring that patient receives ordered dosage . RI #31 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with a diagnosis of Dementia. Review of RI #31's physician orders dated 7/1/2017 through 7/31/2017, revealed: . POLYETHYLENE GLYCOL 3350 POWD, Generic for: MIRALAX POWDER MIX 1 SCOOP (17 GM) (grams) WITH 8 OZ (ounces) OF FLUIDS AND DRINK BY MOUTH ONCE DAILY. DX (diagnosis): BOWEL REGULARITY On 07/13/2017 at 10:00 a.m. during medication pass observation, the surveyor observed EI #5, LPN (Licensed Practical Nurse) administer medications to RI #31. EI #5 measured eight ounces of water in a clear plastic, graduated cup. The surveyor observed EI #5 measure 17 grams of Miralax into the lid from the container of Miralax and pour the medication into the cup containing eight ounces of water. EI #5 inserted a straw into the cup and stirred the mixture. EI #5 knocked on RI #31's door and entered the room with medications. EI #5 handed the plastic cup with the Miralax mixture to RI #31 to drink. Approximately one-half of the Miralax mixture was left in the cup. RI #31 handed the cup containing the remaining Miralax mixture back to EI #5. EI #5 entered RI #31's bathroom and poured the mixture into the sink and then washed her hands. On 07/13/2017 at 10:48 a.m. in an interview with EI #5, the surveyor asked, what was in the cup she provided to RI #31. EI #5 replied, Miralax was in the cup of 8 oz. of water, the Miralax was 17 gms. The surveyor asked EI #5, did RI #31 consume all the substance/liquid in the cup. EI #5 said, No, half. The surveyor asked, did RI #31 receive the prescribed dosage of Miralax if RI #31 consumed half of the water that it was dissolved in. EI #5 answered, No. EI #5 was asked, would that be considered a medication error. EI #5 said, It should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, a review of the facility's policy titled, Incontinent Resident - Care of and [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #2, washed her hands and changed her gloves after cleaning the front perineal area and before cleaning Resident Identifier (RI) #8's buttocks. Further, the facility failed to ensure a CNA, EI #3, washed her hands and changed her gloves before applying barrier cream to RI #8's buttocks. This affected one of two residents observed during incontinence care. Findings Include: A review of the facility's policy titled, Incontinent Resident - Care of with a revision date of 1/20/2016, revealed: . PROCEDURE: . 2. Clean downward from front to back with one stroke. Use a clean wipe for each stroke. 5. Wash hands and apply new gloves. 6. Clean the rectal area; . A review of [NAME] and Perry's FUNDAMENTALS OF NURSING NINTH EDITION,Unit V (5), page 458, revealed: . the WHO (World Health Organization)(2009) recommend the following hand hygiene guidelines: 1. When hands are visibly dirty, when hands are soiled with blood or other body fluids, . 3 .After contact with body fluids or excretions, . When moving from a contaminated to a clean body site during care . RI #8 was admitted to the facility on [DATE], with a diagnosis to include Alzheimer's Disease. During an incontinence care observation for RI #8 on 7/12/2017 at 11:44 a.m., a CNA, EI #2, did not wash her hands and change her gloves after cleaning the front perineal area and before cleaning the buttocks. Further, EI #3 did not wash her hands and change her gloves after cleaning RI #8's buttocks and prior to applying barrier cream. An interview was conducted on 7/12/2017 at 3:10 p.m., with EI #2 and EI #3. EI #2 was asked when should hands be washed and gloves changed during incontinence care. EI #2 stated, After touching anything dirty. EI #2 was asked what should be done after cleaning the front perineal area and before cleaning the buttocks. EI #2 stated, Wash your hands and change your gloves. EI #2 was asked what was the potential for harm in not washing hands and changing gloves. EI #2 replied, Spread of infection. EI #3 was asked what should be done after cleaning the buttocks and before applying barrier cream. EI #3 stated, Wash your hands and change gloves. EI #3 was asked if she did that. EI #3 said, I don't think so. EI #3 was asked what was the potential for harm in not washing hands and changing gloves before applying barrier cream during incontinence care. EI #3 replied, UTI (urinary tract infection). An interview was conducted on 7/13/2017 at 8:36 a.m., with EI #4, a Licensed Practical Nurse/ Infection Control Nurse. EI #4 was asked when should hands be washed and gloves changed during incontinence care. EI #4 stated, When going from one area to another, anytime you change your gloves, at the beginning of a skill and after a skill. EI #4 was asked what must be done after cleaning the front perineal area and before cleaning the buttocks. EI #4 stated, Wash your hands and apply new gloves. EI #4 was asked what should be done after cleaning the buttocks and before applying barrier cream. EI #4 stated, Wash your hands and apply new gloves. EI #4 was asked what was the potential for harm in not washing hands and changing gloves before applying barrier cream during incontinence care. EI #4 replied, Risk of contamination.

Based on observation, interview and review of the Food Code 2013, the facility failed to ensure the outside grease bin was free of grease build up on the outside of the bin and free of debris on the inside of the bin. This was observed on 7/11/17, and had the potential to affect all residents residing in the facility. Findings Include: The Food Code U.S. Public Health Service FDA 2013 states: .5-501.116 Cleaning Receptacles. (B) Soiled receptacles and waste handling units for REFUSE, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. On 7/11/17 at 2:28 p.m., the Surveyor along with Employee Identifier (EI) #1, Dietary Manager, observed the outside grease bin. The bin was dirty and had black grease build up on the outside of the bin and debris on the inside of the bin. On 7/12/17 at 3:30 p.m., an interview was conducted with EI #1. EI #1 was asked if the outside grease bin should be free of grease build up on the outside of the bin. EI #1 replied she was unsure because it had never been brought up before. EI #1 was asked if the inside of the grease bin should be free of debris. EI #1 replied she could see the purpose to allow for proper drainage. EI #1 was asked what was the potential harm of the grease bin having grease build up on the outside and debris on the inside. EI #1 responded it could attract pests.