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Based on observation, staff interview, and policy/procedure review, the facility failed ensure expired medications were not available for patient use and multi-dose medications were labeled with the date opened and/or beyond use date on one (1) of four (4) days of survey.

Findings Include:

Observation of Therapy Department Wound Care supply cabinet at 11:25 a.m. on 04/19/2023 with the Director of Therapy revealed the following expired medications and opened medications not labeled with date opened and/or Beyond Use Date (BUD):

- Povidine/Iodine Prep Pads, expiration date 04/2003, quantity 24
- Hibiclens, 8-ounce bottle, opened, no opened date and/or BUD, expiration date 02/2018, quantity (1) one
- Sensi-Care with 15% zinc oxide, opened, no open date and/or BUD, expiration date 05/2019, quantity (1) one
- Hydrogen Peroxide 3% solution, opened, no open date and/or BUD, expiration date 02/2020, quantity (1) one
- Covidian Iodaform packing strip 1/2inch X 15 feet, opened, no opened date and/or BUD, expiration date 02/2017, quantity (2) two
- Covidian Iodaform packing strip ½ inch X 15 feet, expiration date 05/2022
- Good Neighbor Pharmacy Triple Antibiotic Ointment, opened, no open date and/or BUD, expiration date 04/2020, quantity (1) one
- Convatec Aquacell adhesive dressing 4inch X 10inch, expiration date 11/01/2021, quantity (1) one
- Kendall Calcium Alginate dressing, expiration date 12/2021, quantity (5) five
- Kendall Calcium Alginate dressing, expiration date 10/2022, quantity 10
- Lidocaine Hydrochloride 30 milliliters, opened, no open date and/or BUD, expiration date 2/2020, quantity (1) one
- Duoderm Hydroactive Gel 30 grams, expiration date 01/2017, quantity (1) one

During an interview with the Therapy Director on 04/19/2023 at 11:28 a.m., it was confirmed the expired medications and opened medications not labeled with date opened and/or BUD were found in the Therapy Department wound care supply cabinet.

Review of the facility's policy, "Expired and Unusable Medication," policy number S-3.06, dated 12/01/2010 revealed, " ...Unusable medications include medications that are expired ...mislabeled ...(missing) ...Unusable Medications ...on a patient care unit are returned to the pharmacy ..."

During the exit conference on 4/20/2023 at 12:15 p.m. with the Director of Nursing and Human Resources Director survey findings were discussed, and no further documentation was submitted for review.