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Based on observation, document review and interview, the facility did not ensure that expired medications were not available for patient use.

Findings Include:

Inspection of the medication cupboard in the Physical Therapy Gym on 9/18/19 revealed the following outdated medications and related supplies:

2 Sodium chloride "bullets" - 5 ml, expired 5/10 and 5/15.
2 Acetic Acid 2% in Aqueous Aluminum Acetate Otic Solution - 60 ml, expired 4/18. One of the solutions included an opening date of 2/23/17.
15 vials of Dexamethasone Sodium Phosphate - 4 mg/ml, expired 7/19.

1 Ionto Patch SP - 1 system, expired 3/15.
1 Electronic Transdermal Iontophoretic Drug Delivery system - 3 systems, expired 7/15.
1 Electronic Transdermal Iontophoretic Drug Delivery system, expired 5/16.
Activia patch - 3 systems, expired 5/19.

Review of policy "Medications in PT Department", revised 9/14 revealed that medications will be dated when opened. The policy does not address when an opened medication should be discarded or a process to ensure the removal of expired medications from the patient care area.

Interview with Staff (N), Physical Therapist on 9/18/19 revealed no knowledge of the process for ensuring expired medications are removed from the patient care area.

Based on observation and interview the facility does not ensure biohazardous waste, specifically sharps containers, are properly secured and removed from patient care areas within 30 days in accordance with Title 10 New York Codes, Rules and Regulations Part 70-2.

Findings Include:

Observation in the 2nd floor medication room on 9/17/19, the operating room (OR), the OR soiled utility room and the Physical Therapy Gym/Cardiac Rehab unit on 9/18/19 revealed sharps containers that were not secured in a safety device to prevent tipping and spillage of contents.The containers were not dated.

Observation in room 2043 and 2044 on 9/17/19 revealed wall secured sharps containers that were not dated.

Review of policy "Regulated Medical Waste Management", last revised 1/19 revealed the securing and disposal of sharps containers at least every 30 days is not addressed.

Interview with Staff (B), Nurse Manager on 9/17/19 and Staff (R), Staff Nurse and Staff (J), Director of Business Operations on 9/18/19 verified the above findings.

Based on document review, observation and interview, the facility did not ensure the neonatal and pediatric Emergency Department crash carts are checked in accordance with facility policy.

Findings Include.

Review of policy "Crash Cart, Checking Of", last revised 6/17 revealed locked crash carts will be opened the first of every month by the assigned nursing staff member. Each item on the checklist is to be checked and signed by the assigned staff member.

Observation of the neonatal and pediatric crash carts located in the Emergency Department on 9/17/19 revealed no documentation to indicate that the carts were opened and contents checked on a monthly basis. The only documentation was for "lock integrity".

Interview with Staff (B), Nurse Manager on 9/17/19 verified the above finding.

Based on document review and interview the facility did not maintain humidity within acceptable standards in one of two operating rooms.

Findings Include:

Review of the temperature and humidity logs for operating room # 1 on 09/19/2019 at 12:30 PM revealed that in July 2019 humidity was measured on 17 days with all days exceeding 60%. In August 2019, humidity was measured on 19 days with 12 of the days exceeding 60%.

Interview with Staff (P), Facilities Manager on 09/19/2019 12:30 PM, revealed that maintenance staff are notified when humidity is out of range, but they do not document what adjustments are made or the results. The facility does not have a written procedure for addressing when temperature and humidity are out of range.