Based on observation, interviews, and record reviews, the facility failed to ensure expired intravenous (IV) fluids were not available for use in 1 (Medication Supply Room a) of 1 (Medication Supply Room a) medication supply room observed for expired supplies. Findings: Review of the University Healthcare System (UHS) Policy, titled UHS Expired Supplies and Supply Rotation, last updated 04/2024, revealed in part, to ensure patients are protected from infection and other potential harm from expired or compromised supplies and devices, UHS Hospital assures that supplies are stacked to the most optimal par levels, and supply items have not passed their expiration dates. Further review revealed, in part, under Definitions, Patient Supply- any item that is used on a patient directly or indirectly will remain within the current unexpired date. (Blood tubes, IV catheter, IV solution, X-ray film). Review of the UHS Policy titled, UHS Medication Expiration Dates, last updated 03/2024, revealed in part, the active inventory for medications shall not contain expired medications. Further review revealed, in part, when medications are received, the dates of expiration shall be checked. Further, the bulk storage sections and the IV room shall be checked routinely by personnel for pharmaceuticals that are expired. Observation on 02/12/2025 at 1:51PM, accompanied by S3Staff Registered Nurse (S3Staff RN), of the Medication Supply Room a, located in the automated dispensing cabinet (ADC), bin #28, revealed one (1) 1000 milliliter (ml) bag of Potassium Chloride 10 mill equivalence (meq), with an expiration date of April 2024. Further observation revealed one (1) 1000 ml bag of Potassium Chloride 10 mill equivalence (meq) was available for resident use. In an interview on 02/12/2025 at 1:54PM, S3Staff Registered Nurse (RN) indicated the Medication Supply Room a automated dispensing cabinet was checked by the pharmacy department personnel as per their guidelines. S3Staff RN further indicated it is responsibility of the skilled nursing staff to assure supplies / intravenous fluids (IV)/ medications are within the acceptable date and are not expired and available for resident use. In an interview on 02/12/2025 at 2:15PM, S1RN Director of Nursing (DON) indicated she was informed by S3Staff RN of one (1) 1000 ml bag of Potassium Chloride 10 meq with an expiration date of April 2024, was located in the Medication Supply Room a, in the ADC, bin #28. S1RN DON further indicated there should not have been any supplies / IV fluids/ medications located in the Medication Supply Room a that were expired and available for resident use. In an interview on 02/12/2025 at 2:46PM, S2Pharmacy Operations Manager (POM) indicated the pharmacy staff supply the ADC with medications and IV fluids and are responsible for ensuring all medications and IV fluids are within the current date and are not expired. S2POM indicated the one (1) bag of 1000ml Potassium Chloride 10 meq, dated April 2024, was expired and should not have been available for resident use.

Based on observation, interviews, and record review, the facility failed to ensure dietary staff donned Personal Protective Equipment (PPE) while passing food trays for 1 (Patient #117) of 1 (Patient #117) patient observed for Contact Isolation Precautions. Findings: Review of the facility's Transmission Based Precautions policy and procedure, revised on 09/2024, revealed, in part, in addition to standard precautions, use contact precautions for specified patients known or suspected to be infected or colonized with epidemiological important microorganisms that can be transmitted by direct contact with the patient (hand or skin to skin contact that occurs when performing patient care activities that require touching the patient's dry skin), or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment. 3. PPE: A fluid -resistant gown and gloves will be worn upon entering the patient's room and removed prior to exiting, followed by hand hygiene. Observation on 02/10/2025 at 11:29AM revealed signage on Patient #117's door which indicated Contact Isolation Precautions. Further observation revealed the signage indicated that everyone must put on a gown and gloves. Observation further revealed S6Dietary Aide entering Patient #117's room without putting on a gown. In an interview on 02/10/2025 at 11:29AM, S6Dietary Aide indicated she was only required to put on a gown when the patient was on droplet precautions. In an interview on 02/13/2025 at 9:35AM, S5Infection Preventionist acknowledged the S6Dietary Aide should have put a gown on before entering Patient #117's room, while he was on Contact Isolation Precautions. In an interview on 02/13/2025 at 11:22AM, S1Director of Nursing (DON), acknowledged S6Dietary Aide should have put on a gown before entering Patient #117's room while he was on Contact Isolation Precautions. In an interview on 02/13/2025 at 11:22AM, S4Director of Post-Acute Services confirmed S6Dietary Aide should have worn a gown when entering Patient #117's room while Patient #117 was on Contact Isolation Precautions as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure expired intravenous (IV) fluids were available for use in1 (Medication Supply Room a) of 1 (Medication Supply Room a) medication supply room observed for expired supplies. Findings: Observation on [DATE] at 09:29 a.m., of the Medication Supply Room a, revealed eight (8) five hundred (500) milliliter (ml) bags of Dextrose, five percent (5%) in water (D5W) of IV fluids with an expiration date of [DATE]. Further observation revealed the eight bags of IV fluids of D5W were available for resident use. In an interview on [DATE] at 09:40 a.m., S3Staff Registered Nurse (RN) indicated the Medication Supply Room a was checked two times per week by the central medical supply personnel. S3Staff RN further indicated it is responsibility of the skilled nursing staff to assure supplies are within the acceptable date and are not expired and available for resident use. In an interview on [DATE] at 11:10a.m., S2RN Director of Nursing (DON) indicated she was informed by S3StaffRN of the eight bags of D5W 500 ml located in the Medication Supply Room a were expired [DATE]. S2RN DON indicated there should not have been any supplies located in the Medication Supply Room a that were expired and available for resident use. S2RN DON was unable to provide a policy and procedure regarding the availability of expired supplies. In an interview on [DATE] at 11:09a.m., S4Supply Tech indicated the central medical supply department delivers IV fluids to the Medication Supply Room a every few weeks. S4Supply Tech indicated he was unaware the IV fluids in the Medication Supply Room a were expired and available for resident use.