**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and review of the facility's policy titled, Medication Labeling and Storage, the facility failed to discard expired syringes stored in one of one medication storage rooms. The deficient practices created the potential to use expired syringes. The facility had a census of nine residents. Findings include: Review of the facility's undated policy titled, Medication Labeling and Storage under the Medication Storage section revealed, 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Under the Medication Labeling section revealed, 2. The medication label includes, at a minimum: medication name (generic and/ or brand; prescribes dose; strength; expiration date, when applicable; resident's name; route of administration; and appropriate instructions and precautions. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding or destroying these items. Interview and observation on [DATE] at 1:40 pm of the medication storage room with the Registered Nurse Supervisor (RNS) revealed a sealed zip lock bag of syringes with expiration date of [DATE]. RNS confirmed the date on the bag was [DATE] and that the syringes were expired. During an interview on [DATE] at 12:34 pm with the Director of Nursing (DON) revealed that the RNS was about to destroy the syringes when she asked what she was doing. She stated that the RNS informed her that the syringes were expired, and she was about to destroy them. DON stated she took the bag and partially opened it and removed the label. DON also stated that the bag of syringes was inside of another bag and the RNS removed it prior to bringing it to her. She stated that she took the bag and contacted the pharmacy for clarification on the expiration date. During an observation and interview on [DATE] at 2:00 pm, the DON presented a bag of syringes without a label that was opened on the side. DON insisted that this was the bag observed the day before and that she removed this bag from the original bag and had cleaned up the bag a bit. DON stated that she used the lot number to contact the pharmacy for clarification and had gotten a letter stating the syringes were not expired. During a follow up interview on [DATE] at 2:30 pm with the RNS revealed that she did not in fact remove the syringes from another bag prior to giving it to the DON. RNS admitted that the sealed bag of syringes was handed to the DON as observed the day before. She also stated that she normally check the expiration dates listed on the packages delivered by the pharmacy and would contact them if there was any doubt or if she had questions but had not contacted them about this situation (expired syringes). During a telephone interview on [DATE] at 8:00 pm with the Director of Clinical Services (DCS) for the pharmacy revealed, that she was aware that at some point everything expires and stated that the pharmacy computer generates labels with expiration dates automatically for items especially the ones removed from their original packaging. The DCS stated that she was only given a lot number and was not sure if that was for the item (syringes) in question. The DCS revealed that she contacted the manufacturer about the lot number she was given and that she was still awaiting a response.

Based on observations, staff interviews, and review of the facility policy titled, Food Receiving and Storage the facility failed to ensure that items were labeled and dated in the satellite kitchen refrigerator, freezer, and dry storage area and in the dry storage area in the main kitchen. This deficient practice had the potential to affect 14 of 14 residents receiving an oral diet. Findings include: Review of the facility policy titled, Food Receiving and Storage, revised November 2022 revealed the following: Dry Food Storage: 4. Dry foods that are stored in bins are removed from the original packaging, labeled and dated (use by date). Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage 1. All food stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so that are used by their use-by date, frozen, or discarded. Initial tour on 1/27/2023 at 8:07 a.m. of the satellite kitchen began with dietary staff present. It was reported that the dietary manager had not made it to the facility for the day. The following was observed: 1. In the freezer there was one box containing ice cream sandwiches that was opened but there was no open date or expiration dates on the box or ice cream bars. 2. In the reach in cooler here was one key lime pie that had been opened (partially eaten) that did not have an open or expiration date on it. 3. There was a pound cake wrapped in clear wrap that did not have an open or expiration date. 4. On the shelves behind the steam table there were 19 small boxes of various cereal that did not have an expiration date. 5.There were two partial loaves of bread that did not have an open or expiration date on them. During an interview and observation on 1/27/2023 at 3:13 p.m. with the Certified Dietary Manager (CDM) AA he reported that he had already removed the pie and from the refrigerator after surveyor's initial tour. CDM AA reported that both items were from the day before. The ice cream sandwich bars remained in the freezer and did not have an open date or an expiration date. The cereal remained on the shelves and CDM AA reported that he put the cereal in the kitchen and rotated them first in and first out. However, there were no dates on the boxes of cereal and he reported that he would have to contact the company to determine when the items expire because they have codes on them. CDM AA confirmed that the loaves of bread did not have an expiration date. A brief tour on 1/27/2023 at 3:37 p.m. of the main kitchen was conducted with CDM AA and the following was observed during the tour: 1. There was one #10 can of sliced jalapenos noted to be dented. 2. There was one #10 can of tomatoes noted to be dented and without an expiration date. 3. There were six cans of sweet potatoes, six cans of dark kidney beans, and 10 cans of roasted red peppers that did not have expiration dates or received date. There were codes on the can, but the CDM AA was not able to identify the expiration date. During an interview on 1/29/2023 at 12:21 p.m. with CDM AA revealed that each staff member is responsible for labeling and dating items on their shift. He acknowledged that he discarded the cereal because they did not have a date on them, and he was the person that had placed them in the satellite kitchen. It was reported that the Director of Dining and CDM were responsible to make sure the use by date is made known to staff. CDM AA reported that the ice cream sandwich bars were taken from the original box and the expiration date was on that box. Lastly, he reported that the bread came from the freezer in the main kitchen and should have had an expiration date when placed in the satellite kitchen. Continued interview with CDM AA also revealed that dented cans were typically identified during delivery and returned to the vendor by the driver. Interview on 1/27/2023 at 1:03 p.m. with the Administrator who acknowledged that an in-service had been provided to staff earlier in January 2023 related to meal service which included labeling and dating items. He reported that this information has not been incorporated into the Quality Assurance Program yet, but they would be meeting soon. The Administrator then provided documentation of education provided to staff on 1/27/2023 related to labeling and dating of items.