Based on observation, interview, and policies, it was determined that the facility failed to ensure that expired medications were removed from the emergency kit (E-kit) stored in the medication storage room on the first floor in 1 of 2 storage rooms observed. Findings include: Observation on 11/16/23 of the medication storage room on the first floor revealed an E-kit with a sticker on the top indicating an expiration date of 9/23; within the E-kit revealed six individual boxes with different medications. Review on 11/16/23 of Box 1 review the following expired medications: (6) Citalopram 10 milligrams (mg) expired 9/23 (6) Allopurinol 100 mg expired 8/23 (6) Clopindogrel 75 mg expired 8/26/23 (6) Carbidopa-levodaopa expired 9/23 (6) Carvedilol 3.125 mg expired 8/1/23 Review on 11/16/23 of Box 2 revealed the following instructions EMERGENCY KIT-BOX 2 Drugs Dip to Lev ** RECORD ALL MEDS [Medications] REMOVED FROM KIT WITH PATIENTS FULL NAME AND DATE OF REMOVAL** . Review revealed that on 11/4/23 Eliquis 2.5 mg was removed from Box 2 for Resident #30. Further review of Box 2 the following expired medications were noted: (1) Gabapentin expired 9/10/23 Review on 11/16/23 of Box 3 review the following expired medications: (2) Omeprazole Dr 20 mg expired 9/7/23 (6) Metformin HCL expired 8/5/23 (1) Olanzapine expired 11/3/23 (2) Olanzapine expired 8/25/23 Review on 11/16/23 of Box 4 review the following expired medications: (6) Prednisone 1 mg expired 9/7/23 (1) Risperidone 0.25 mg expired 9/10/23 Review on 11/16/23 of Box 5 review the following expired medications: (25) Nitro 0.4 mg expired 10/23 Review on 11/16/23 of Box 6 review the following expired medications: Glucagon Emergency Kit for low Blood sugar expired 10/27/23 Interview on 11/16/23 at 3:00 PM with Staff C (Director Of Nursing) indicated that the pharmacy has not been monitoring the E-kit because the facility was using a new automated medication storage and inventory system. Review of the facility's policy not dated, titled Disposal of Dropped, Refused, Expired or Discontinued Medications revealed, Risk Category 2 Policy .3. Methods of disposition of pharmaceutical hazardous and non-hazardous waste are consistent with applicable state and federal requirements, local ordinances, and standards of practice. The nursing home will use an approved vendor for pharmaceutical waste disposal needs. PharmMerica provides this service . 2. return of Non-Controlled Medication: b. Expired or Discontinued medications which have been at the facility for over 45 days shall not be returned to the pharmacy-PLEASE CHECK -LABEL for date DISPENSED NOT DR Issue date) and follow the procedure for Bulk Destruction. Review of the Pharmacy Service Agreement on 11/17/23 signed on 7/7/30/21 by Staff F (Administrator) and continues until 6/30/24, revealed 2. Obligations of the Pharmacy . C. Pharmacy shall provide. maintain and replenish emergency drug supply kits (Emergency Kits) as permitted by Applicable Law. Emergency Kits are property of Pharmacy as required by Applicable Law. Pharmacy shall deliver Products on a Stat basis when the contents of Emergency Kits cannot satisfy the needs of Customer . E. Pharmacy shall label all dispensed Medications in accordance with Applicable Law and currently accepted professional standards. Obligations of the Client revealed the Client shall, or require the Customer to, as the case may be: .K. Store and handle all Medications in accordance with Applicable Law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure that staff demonstrated proper use of gloves and hand hygiene during a dressing change for 1 out of 1 resident observed (Resident identifier is #14). Findings include: Observation on 11/15/22 at 2:49 p.m. of Resident #14's dressing change on right foot #5 metatarsal head with Staff B (Registered Nurse) revealed Staff B donned gloves, moved a urinal on the nightstand, gave Resident #14 a cup of pills then proceeded to clean Resident #14's wound with wound wash on a gauze pad. Staff B removed foam dressing from the package and with the same gloves, prepared the dressing by cutting with scissors, placed a small piece of foam dressing onto the wound, and covered with another foam dressing. Staff B had not performed any hand hygiene or changed his/her gloves during this procedure. Interview on 11/15/22 at 3:00 p.m. with Staff B confirmed that he/she did not change gloves. Interview on 11/15/22 at 2:55 p.m. with Staff F (Registered Nurse Wound Care Certified) confirmed the above observation. Review on 11/16/22 of the facility's policy titled Hand Hygiene (not dated) Risk Category 2 Standard: Hand Hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare setting When To Wash Your Hands at a Minimum * Before and after each resident contact * After touching a resident or handling his or her belongings or food * After contact with any body fluids * After handling any contaminated items * Before and after removal of PPE Review on 11/16/22 of the facility's policy titled Dressing Change Procedure (not dated) Risk Category 1 Procedure 3. Establish clean field in resident room for supplies. 4. Using aseptic technique, open dressings supplies Review on 11/17/22 of the Centers for Disease Control and Prevention Hand Hygiene in Healthcare Settings retrieved from https://www.cdc.gov/handhygiene/providers/index.html read, in part, . Introduction to Hand Hygiene . Why Practice Hand Hygiene? Cleaning your hands reduces: the spread of potentially deadly germs .use an alcohol-based hand sanitizer . before moving from work on a soiled body site to a clean body site on the same patient . After contact with blood, body fluids, or contaminated surfaces . Glove Use . Change gloves and perform hand hygiene during patient care, if . gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body sited on the same patient . Review on 11/17/22 of [NAME], [NAME] A., and [NAME]. Clinical Nursing Skills & Techniques. 10th edition St. Louis, Missouri: Mosby Elsevier, 2022. pg. 1127; Performing a Wound Assessment .7. Perform hand hygiene. 8. Explain procedure of wound assessment to patient . 10. Apply clean gloves and remove soiled dressings; remove gauze one layer at a time. 11. Examine dressing for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressing were saturated, slightly moist, or had no drainage). Discard dressing in waterproof biohazard bag. Remove and discard gloves. 12. Perform hand hygiene and apply clean gloves.