Based on record review, interview, a document titled, CODE OF ALABAMA 1975 .ALABAMA STATE BOARD OF PHARMACY and review of a facility policy titled, Medication-Destruction Controlled Drugs, the facility failed to ensure three required signatures were obtained for controlled drug destruction for July 2017. This affected one of thirteen months of medication destruction records reviewed. Findings Include: Review of CODE OF ALABAMA 1975 .Practice of Pharmacy Act 205 Legislature 1966 ALABAMA STATE BOARD OF PHARMACY revealed the following: .7. For destruction of controlled substances, there shall be a third witness who may be a law enforcement official, management or supervisory personnel, i.e.(for example), administrator, LPN (Licensed Practical Nurse) charge nurse, etc (and so on) . A review of a policy with a revised date of 1/31/2009, titled, Medication-Destruction Controlled Drugs, revealed: Subject: Storage and Destruction of Discontinued Narcotics .Destroying of Controlled Drugs: *Destruction of controlled drugs must be done by Pharmacist, DON (Director of Nursing) (or designee) and other Licenses (licensed) Nurse . On 02/15/2018 at 1:50 PM, the surveyor reviewed thirteen months of drug destruction records for controlled medications. These thirteen months of drug destruction were from January 2017 through January 2018. The controlled record of destruction required three signatures; a registered nurse, the pharmacist and a witness. The July record, with signatures made on 7/3/2017, only showed two signatures. No witness signature was made on the two documents for this month. On 2/15/2018 at 2:30 PM, an interview with EI (Employee Identifier) #5, the Director of Nursing, was conducted. EI #5 was asked, who was responsible for medication destruction at the facility. EI #5 replied, that would be her. EI #5 was asked, how often were the controlled medications destroyed. EI #5 replied, typically once per month but there could be a month with none. EI #5 was asked, how many signatures were required for medication destruction for controlled drugs. EI #5 replied, three. EI #5 was asked, from whom should these signatures be obtained. EI #5 replied, Pharmacist, RN (Registered Nurse) and a witness. EI #5 was asked, on the record of medication destruction dated 7/3/2017, were three required signatures obtained. EI #5 replied, no. EI #5 was asked, what was the potential negative outcome from not obtaining three required signatures for records of medication destruction for controlled medication. EI #5 replied, a potential negative outcome could be that drugs were not destroyed properly.

Based on observation, interview and a policy titled, Personal Hygiene Training, the facility failed to ensure dietary workers' hair was contained inside of hair restraints while working in the kitchen. This was observed on two of three days in the kitchen, and had the potential to affect all 83 residents who were served meals from the kitchen. According to the RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form,the census was 84. Findings Include: A review of a undated policy, titled, Personal Hygiene Training, revealed: .4. Keep hair neat and clean. Wear a hair restraint when around exposed foods, in the kitchen or food service areas including dining areas. On 02/13/18 at 2:38 p.m., an observation of EI (Employee Identifier) #3, the Dietary Manager, was made with hair unrestrained about 1/4 inch wide and three inches long at the ear and at the neckline with some pieces of hair hanging out from underneath the hair restraint. On 02/14/18 at 11:19 a.m., an observation was made of EI #1, a Dietary Worker. EI #1 had hair exposed at the neckline, about 1 and 1/2 inches, with no hair restraint covering it. At this time EI #2, a Dietary Worker, was observed with hair all along the edge of the hair restraint, around the ears showing and hanging down outside of the hair restraint. Another observation was made at the same time of EI #3 with hair in clusters hanging out all around at the edges of the hair restraint . On 02/15/18 at 12:42 p.m., an interview was conducted with EI #1. EI #1 was asked, when should hair restraints be worn. EI #1 stated, anytime staff was in the kitchen. EI #1 was asked, how should hair restraints be worn. EI #1 said, to cover any hair on the head and face. EI #1 was asked, why should hair restraints be worn in the kitchen. EI #1 said to keep hair out of whatever food he was preparing or serving. An observation of a staff member with their hair restraint exposing the back neckline (1 and 1/2 inch of the hair) was shared with EI #1. EI #1 was asked if that was an appropriate way to wear a hair restraint. EI #1 stated, no. An observation made of a dietary staff member with their hair hanging in strands around the outside of the hair restraint was shared with EI #1. EI #1 was asked if that was the proper way to wear a restraint. EI #1 stated, no it was not. An observation made of a dietary worker with hair hanging out around the edges of the hair restraint was shared with EI #1. EI #1 was asked if that was an appropriate way to wear the hair restraint. EI #1 stated, no ma'am. EI #1 was asked when should hair restraints be worn inside of the kitchen. EI #1 stated, anytime. EI #1 was asked what was the facility policy on wearing hair restraints. EI #1 stated, anytime staff was in the kitchen, all hair should be covered. EI #1 was asked what was the potential negative outcome of not correctly wearing a hair restraint in the kitchen. EI #1 stated, hair in the product. On 02/15/18 12:55 p.m., an interview was conducted with EI #2. EI #2 was asked when should hair restraints be worn. EI #2 stated, before she came in the kitchen. EI #2 was asked why should hair restraints be worn in the kitchen. EI #2 stated, to keep hair from getting in the food or on the plate. EI #2 was asked how should hair restraints be worn. EI #2 stated, to cover the whole head and facial hair if the person had it, including side burns. An observation made of a staff member with their hair restraint exposing the back neckline of hair was shared with EI #2. EI #2 was asked if that was an appropriate way to wear a hair restraint. EI #2 stated, no ma'am. An observation made of a dietary staff member with their hair hanging in strands around the outside of the hair restraint was shared with EI #2. EI #2 was asked if that was a proper way to wear a hair restraint. EI #2 stated, no ma'am. EI #2 was asked when should hair restraints be worn inside of the kitchen. EI #2 replied, before entering the kitchen. EI #2 was asked, what was the facility policy on wearing hair restraints. EI #2 replied, wear the hairnet at all times (in the kitchen). EI #2 was asked what was the potential negative outcome of not wearing a hair restraint in the kitchen. EI #2 stated, hair might fall in the food and the possibility a resident might not want to eat the food. On 02/15/18 at 1:09 p.m., an interview was conducted with EI #3. EI #3 was asked when should hair restraints be worn. EI #3 stated, when they (staff) enter the kitchen. EI #3 was asked why should hair restraints be worn in the kitchen. EI #3 stated, to keep hair out of food. An observation made of a staff member with the hair restraint exposing the back neckline was shared with EI #3. EI #3 was asked if that was an appropriate way to wear a hair restraint. EI #3 stated, no. An observation made of a dietary staff member with their hair hanging in strands around the outside of the hair restraint was shared with EI #3. EI #3 was asked if that was the proper way to wear a hair restraint. EI #3 stated, no. EI #3 was asked when should hair restraints be worn inside of the kitchen. EI #3 stated, whenever staff was in the kitchen. EI #3 was asked what was the facility policy on wearing hair restraints. EI #3 stated, to wear a hair restraint when around exposed food. EI #3 was asked what was the potential negative outcome of not wearing a hair restraint in the kitchen. EI #3 stated, someone could find a hair in the food.

Based on observation, interview and the Food Code U.S. Public Health Service and FDA (Food and Drug Administration)2013, the facility failed to ensure that the grease trap grill was free from excessive debris and trash, which had the potential to attract rodents and pests. This was observed on one of three days and had the potential to affect all 84 residents who reside in the facility. Findings Include: A review of an undated facility policy titled, POLICY FOR USED COOKING OIL, revealed: ALL DISCARDED COOKING OIL WILL BE MAINTAINED IN OUTSIDE CONTAINER FOR PICKUP BY DESIGNATED COMPANY, . .MAINTENANCE WILL KEEP AREA AROUND FREE OF DEBRI (DEBRIS) . A review of a contract with the designated waste company revealed: .b. Remove and replace containers of cooking oil from Client's premises on a regular schedule agreed upon by the parties or upon notification . A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed: . 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE, recyclables, or returnables shall be maintained free of unnecessary items, .and clean . 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 02/13/18 2:50 p.m., an observation was made of the grease trap. The grease trap had a mound about nine inches high of fried, cooked debris on top of the grease trap grill. On 02/15/18 1:09 p.m., an interview was conducted with EI (Employee Identifier) #3, Dietary Manager. EI #3 was asked how often did the facility have the grease trap cleaned out. EI #3 stated, monthly. EI #3 was asked when was the last time the facility grease trap was cleaned. EI #3 stated, January. EI #3 was informed of the observation on 2/13/18, of the grease trap with about a nine inch mound of a fried substance on the grill of the grease trap. EI #3 was asked if that was appropriate. EI #3 stated, she did not know. EI #3 was asked who was responsible for cleaning the grease trap. EI #3 stated, maintenance. EI #3 was asked what was the facility policy on disposing of grease into the grease trap and cleaning it. EI #3 stated, they just poured the used grease in the bin and the company disposed of it. EI #3 was asked, what was the potential negative outcome of allowing debris to build up on the grease trap and not be cleaned off. EI #3 stated, she did not know. On 02/15/18 1:38 p.m., an interview was conducted with EI #4, the Maintenance Director. EI #4 was asked how often did the facility have the grease trap cleaned out. EI #4 stated, quarterly, but they were having trouble finding someone to do it. EI #4 said no one cleaned the grill in between. EI #4 said a company pumped it out but maintenance did nothing in between.