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Based on observation, interview, and record review, the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

Findings included:

During a tour of the Emergency Department with Staff #27, on 6/26/19 afternoon, the following observations were made:
- Clean Utility room: 16 tubes of 2.5 fl. oz. Actidose (poison adsorbent) of which 5 tubes had expiration date of 04/2019. Additional 11 tubes which were placed behind the 5 expired tubes had expiration date of 05/2020.

In an interview on 6/26/19 at 1:30 pm, Staff #27 confirmed the above findings and stated the 5 tubes of expired Actidose should be discarded. Staff #27 stated night shift staff usually checked for expired medications daily. When asked for documentation of inventory checks, Staff #27 stated they did not keep any logs or documentation. Staff #27 further stated any staff who identified expired medications were to call pharmacy immediately for pick up.

Review of facility policy titled Medications- locations, restocking, monitoring, with approved date of 1/19/09, and most recently reviewed on 4/26/19, reflected " ...Medications are counted and restocked daily, Monday through Friday, by the pharmacy personnel. The pharmacy is responsible for monitoring the expiration dates on medications."

Based on observation, interview, and record reviews, the facility failed to ensure an adequate system for identifying, reporting, investigating and controlling infections of patients and personnel when:

1) Expired food items found in dry storage area
2) Improper storage of kitchen supplies and equipment
3) Chemical test strips not used as needed at the dish washing station for pots and pans

Findings included:

1) During a tour of the kitchen with Staff #6, on 6/25/19 afternoon, the following observations were made:
- Walk-in fridge: 2 bags of 16 count hot dog buns with expired date of 4/19; 3 bags of Pepperidge Farm bread without any expiration date; 1 bag of graham cracker crust with used by date of 6/18.
- Dry Storage Unit: multiple packets of Hidden Valley Italian dressing with best by date of 12/21/16; multiple packets of Newmans Own Italian dressing with best by date of May/19/19 (these dressings were mixed in with other non-expired dressings).

In an interview on 6/25/19 at 2:50 pm, Staff #6 confirmed the above findings. Staff #6 stated expired food should not be served and thrown away, should not be mixed in with other non-expired food items, and food items should have expiration date written. Staff #6 further stated facility policy is to discard all food items after the best by, use by, and expired date.

Review of facility policy titled Food Storage: Labeling, with revised date of 04/17/19, reflected "all food stuffs received will be dated and placed in appropriate storage areas ...product to be placed in appropriate are behind like product for older product to be used first (First In, First Out)."

Review of facility policy titled Food and Supply Storage, with approved date of 4/2019, reflected " ...products are checked for ...freshness and date of use."

Review of facility policy titled Patient Food Refrigerators-Freezers, with revised date of 1/15/19, reflected " ...if an item does not have a printed expiration date on the container, and expiration date shall be written on the container by food service, nursing, or department personnel ....the label may state 'expiration date' or 'use by' ...if a food is questionable and/or not identified, nor dated, the item is discarded."

2) During a tour of the kitchen with Staff #6, on 6/25/19 afternoon, the following observations were made:
- Dry Storage Unit: bottom shelves of approximately eleven 6-tier storage shelving units did not have an impermeable surface.
- Kitchen area: bottom shelf of one 6-tier storage shelving unit did not have an impermeable surface.

These conditions expose kitchen equipment and supplies stored on these bottom shelves to potential splash and contamination.

In an interview on 6/25/19 at 2:50 pm, Staff #6 confirmed the above findings. Staff #6 stated she wasn't aware of the requirement but understood the rationale for needing impermeable surface for the bottom shelves in order to prevent potential splash and contamination.

Review of facility policy titled Infection Control-Nutrition Concepts-Storage of Dishes, Pots, Pans, and Eating Utensils, with revised date of 04/16/19, reflected "cooking and serving utensils will be stored in a safe manner."

Review of facility policy titled Nutrition Concepts- Cleaning and Sanitizing-Equipment, with revised date of 04/1/19, reflected "Nutrition Concepts employees will clean, sanitize, store, and cover if needed, all utensils and equipment after each use..."

3) During a tour of the kitchen with Staff #6, on 6/25/19 afternoon, a cartridge of chemical test strip was affixed to a wall adjacent to a manual ware washing station used for pots and pans.

In an interview on 6/25/19 at 2:38 pm, Staff #6 stated that manual dishwashing station used Oasis 146 Multi-Quat Sanitizer to clean pots and pans, and chemical test strips are used to check for effectiveness of the sanitizer. Staff #6 further stated staff used the chemical test trips when using the manual dishwashing station. When asked for records of chemical strip testing, Staff #6 stated "facility staff do not use the chemical strips to verify sanitizer effectiveness ...there is no record or log ...Ecolab (company that provides the sanitizer) comes once a month to test with the strip but there's no log for that either." When asked for a policy related to chemical strip testing, Staff #6 stated "there is no policy on strip testing." When asked how the staff ensured effectiveness of the sanitizer without using chemical test strips, Staff #6 stated "I get what you're saying."

Review of facility policy, furnished on 6/26/19 morning, titled Sanitize solution test and use for Manual ware washing, with approved date of 6/25/19, reflected "each time the Pot and Pan compartment sinks are used for washing soiled equipment the sanitizing solution water is to be tested by strips for proper dilution ... procedure ...(3.A.3.) Compare colors at once on the packet cover ...record results on Sanitizer Log Sheet."

Review of Ecolab manufacturer product specification document titled Oasis 146 Multi-Quat Sanitizer, with reference #910787, reflected " ...clean equipment with a good detergent and follow with a potable water rinse, then rinse equipment with a sanitizing solution of 1 oz. to 2.6 oz. Oasis 146 Multi-Quat Sanitizer per 4 gallons of water (150-400 ppm)." The 150-400 ppm range is determined by using a chemical test strip.