Dci Monroe

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 49828 Based on one of one observation of the emergency evacuation box in the In-center Hemodialysis Unit (ICHD), staff interview, and review of facility documents, it was determined that the facility failed to ensure that the evacuation box contains the items outlined on the checklist and is checked monthly in accordance with the facility policy and procedure. Findings include: On 12/3/24 at 11:30 AM, the emergency evacuation box for the ICHD was opened and reviewed with the list of contents. The following items on the list were not present in the evacuation box: Progress notes, and current telephone/address list (patients and staff). During an interview at 11:36 AM, Staff (S) 2, a Charge Nurse, stated he/she reviews the expiration date list and only opens the box to remove expired items, and not to check all the contents monthly. A review of the “DCI NEW JERSEY-EMERGENCY MEDICATIONS & EVACUATION BOX CHECKLIST” revealed a signature date of 6/17/24. The list stated, “Your signature on this list indicates you have checked the following: ... Supplies should be sufficient for 12 patients and check monthly ...” A review of the facility policy titled, “Evacuation Boxes,” revised on 3/21/23 stated, “ ... PROCEDURE: Evacuation Boxes will be maintained in the dialysis unit. They will be checked monthly for verification of contents and expiration dates ... SUPPLIES: Evacuation Boxes will contain appropriate number of the following items: Hemodialysis: ... Progress notes ... Current telephone/address list [patients and staff] ...” N.J.A.C 8:43A-15.1(a)”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 51227 Based on two of two observations of hemodialysis treatment provided through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview, and review of facility documents, it was determined that the facility failed to ensure that hand hygiene is performed in accordance with facility policy. Finding include: During an observation on 12/3/24 at 11:07 AM, in Station 5, Staff (S) 8, a Registered Nurse (RN), cleaned the CVC exit site of the patient and then applied a new dressing onto the exit site. S8, did not remove his/her gloves, perform hand hygiene, and don (put on) new gloves before applying a new dressing. After applying the dressing, S8 then removed his/her gloves, performed hand hygiene, donned new gloves, and drew blood from the CVC. Without removing his/her gloves and performing hand hygiene, S8 touched the dialysis machine and then returned to the patient and scrubbed the CVC hubs before connecting the lines to initiate dialysis. S8, did not remove his/her gloves, perform hand hygiene, and don a new pair of gloves after touching the dialysis machine. During an interview at 11:15 AM, S8 stated he/she should remove gloves and perform hand hygiene when going from dirty to clean, or when touching the machine and going back to the patient. During observation on 12/3/24 at 10:15 AM, in Station 4, S2, a Charge Nurse, was observed disconnecting the dialysis blood lines from a CVC. S2, with gloved hands, touched the patients’ belongings inclusive of a blanket, and headphones. S2 placed the patients’ belongings on the chaise wall and touched the dialysis machine. S2 then drew blood and placed the used vacutainer (a device used to draw blood), and blood tubes onto the clean field. S2 touched the dialysis machine and returned to the patient to check their blood pressure. Once the patients’ blood pressure was assessed, S2 removed the arterial and venous lines from the patients’ CVC. S2 scrubbed and flushed the hubs of the CVC, placed new caps, and covered limbs with gauze and tape. Throughout the procedure, S2 did not remove his/her gloves, perform hand hygiene, and don a new pair of gloves. During an interview at 10:35 AM, S2 stated “there is no need to remove gloves and don new ones during the process of disconnecting a CVC.” Facility policy titled, “HANDWASHING,” revised 3/2023, stated, ... “Hand washing is done: ... f. After handling equipment/supplies ... k. Hands should always be washed after gloves area removed and between patient contacts, as well as after touching blood, body fluids, secretions, excretions, and contaminated items ...” N.J.A.C. 8:43A-24.8(b)”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 37656 Based on one of one observation and staff interview, it was determined that the facility failed to ensure that the Myron L D6 meter (used to check the conductivity and pH [potential of hydrogen] to ensure quality and safety of the dialysate before it is used in dialysis treatment of patients) is disinfected after use in the patient’s dialysis station, before being stored in a clean area. Findings include: On 12/3/24 at 11:10 AM, Staff (S) 4, a Patient Care Technician (PCT), was observed taking the Myron L D6 meter from the clean sink to Station 4 to perform pH and Conductivity testing. S4 returned the Myron L meter to the clean sink for storage. S4 did not clean and disinfect the meter prior to placing it back on the clean sink. Upon interview at 11:25 AM, S4 stated that the Myron L meter was always stored at the clean sink, and since it was only touching the clean machine, it did not need to be cleaned and disinfected. Facility policy titled, “Myron L D6 Meter Disinfection, Calibration, Use and Storage,” issued 1/26/2023, did not include policy for disinfection of the machine. N.J.A.C. 8:43A-24.8(b)”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 49828 Based on four of four observations of cleaning and disinfection of the dialysis stations, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that all surfaces at the dialysis station are cleaned and disinfected after patient use. Findings include: On 12/3/24 at 10:05 AM, in Station 3, a patient completed hemodialysis treatment and was discharged. Staff (S) 5, a Patient Care Technician (PCT), cleaned and disinfected the station by wiping items and surfaces located inside of the station with bleach-soaked cloths. S5 cleaned the blood pressure (BP) cuff and placed it into a caged holder on the left side of the machine that had not been cleaned. S5 then cleaned only the left side of the chaise wall in the patient station and did not clean the oxygen tank located within the station. During an interview at 10:12 AM, a review of the findings were discussed with S5. S5 confirmed he/she did not clean the BP cuff holder before placing the clean BP cuff into it. S5 stated, “I only have to wipe were the patients’ belongings go.” He/she continued to state that the patients’ belongings were only on the left side of the chaise wall therefore, he/she did not have to clean the entire chaise wall. At 10:22 AM in Station 5, a patient completed hemodialysis treatment and was discharged. S4, a PCT, cleaned and disinfected the station by wiping items and surfaces located inside of the station with bleached-soaked cloths. S4 cleaned the hemodialysis machine and chair. S4 did not clean the chaise wall, wall water box, and oxygen tank located within the station. During an interview at 10:28 AM, S4 confirmed they had completed the cleaning and disinfection of Station 5. The findings above were discussed with S4. S4 stated he/she still had to clean the chaise wall and around the wall water box. S4 then returned to the station and cleaned the chaise wall and around the water box, but failed to clean the oxygen tank. During an interview at 10:30 AM, S2, a Charge Registered Nurse (RN), stated the oxygen tanks in each dialysis station must be disinfected between patients. At 10:44 AM in Station 4, a patient completed hemodialysis treatment and was discharged. S5 cleaned and disinfected the station by wiping items and surfaces located inside of the station with bleached-soaked cloths. S5 cleaned the hemodialysis machine and chair. S5 did not clean the chaise wall, or oxygen tank within the station. 37656 At 10:50 AM, S4, a PCT, was observed during cleaning of Station 7. The dialysis chair contained a leather flap on the head portion of the chair. S4 cleaned the surfaces of the chair including the surface of the flap but did not open the flap to clean underneath. Upon interview, S4 proceeded to clean under the flap. Facility policy titled, “Surface Cleaning in the Dialysis Setting,” revised on 3/15/23 stated, “ ... Procedure: ... 4. Table/Chair Cleaning a. Take a cloth saturated with 1% bleach solution ... c. Wipe the ENTIRE chair and table with cloth ... 6. Wall Boxes/chase counter ... c. Wipe external surfaces of wall box and chase counter ...” N.J.A.C. 8:43A-24.8(b)”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 51227 Based one of one observation of initiation of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interview, and review of facility policy, it was determined that the facility failed to ensure proper cleansing of the exit site. Finding include: On 12/3/24 at 11:07 AM, in Station 5, Staff (S) 6, a Registered Nurse (RN) was observed initiating hemodialysis through a CVC. S6 cleansed the exit site with a Chlorhexidine swab. After cleaning the exit site, S6 immediately applied a new dressing. S6 did not allow the exit site to dry for 30 seconds before applying new dressing per facility policy. In an interview at 11:30 AM, S6 was asked about the procedure of cleansing the exit site for a CVC and dry time before putting on a new dressing. S6 was unaware of any dry time before putting on a new dressing. He/she said after cleaning they just put on the new dressing. Upon interview on 12/5/24 at 10:07 AM, S1, a Nurse Manager, was asked about the contact and dry time for a CVC because it is not stated in the CVC policy. S1 stated that they use the AVF/AVG (Arteriovenous Fistula/Arteriovenous Graft) policy and procedure for contact and dry time. Facility policy titled, “Preparation And Cannulation of Arteriovenous Graft (AVG),” last revised August 2024, stated, ... DISINFECTANT Chlorhexidine gluconate ... DRYING TIME 30 seconds or until completely dry ... Procedure: ... 7. ... Allow area to dry completely Do not blot or wipe solution from site. Do not fan, blow or wave air onto the site to promote faster dry time ...” N.J.A.C. 8:43A-24.8(b)”

“MAX LEVEL OF CHEM CONTAM H20/CHEM ANALYSIS CFR(s): 494.40(a) 4 Fluid quality 4.1 Water 4.1.1 Maximum level of chemical contaminants in water: chem analysis Product water used to prepare dialysate or concentrates from powder at a dialysis facility, or to process dialyzers for reuse, shall not contain chemical contaminants at concentrations in excess of those listed in ANSI/AAMI RD62, which is reproduced in Table 1 below: Table 1-Maximum allowable chemical contaminant levels in water used to prepare dialysate and concentrates from powder at a dialysis facility and to reprocess dialyzers for multiple uses (Reproduced from ANSI/AAMI RD62:2001) Contaminant / Maximum concentration (mg/L) Calcium 2 (0.1 mEq/L) Magnesium 4 (0.3 mEq/L) Potassium 8 (0.2 mEq/L) Sodium 70 (3.0 mEq/L) Antimony 0.006 Arsenic 0.005 Barium 0.10 Beryllium 0.0004 Cadmium 0.001 Chromium 0.014 Lead 0.005 Mercury 0.0002 Selenium 0.09 Silver 0.005 Aluminum 0.01 Chloramines 0.10 Free Chlorine 0.50 Copper 0.10 Fluoride 0.20 Nitrate (as N) 2.0 Sulfate 100 Thallium 0.002 Zinc 0.10 NOTE-American National Standards are revised every three to five years. Users should consult the most recent edition of ANSI/AAMI RD62 to ensure that the levels listed in this table are still valid. The manufacturer or supplier of a complete water treatment system should recommend a system that is capable of meeting the requirements of this clause at the time of installation given the analysis of the feed water. The system design should reflect possible seasonal variations in feed water quality. Following installation of a water treatment, storage, and distribution system, the user is responsible for continued monitoring of the levels of chemical contaminants in the water and for complying with the requirements of this standard. This Standard is not met as evidenced by: 48966 Based on one of two water panel sample reviews, staff interview and review of facility policy, it was determined that the facility failed to ensure a chemical analysis of the water is performed every six months in accordance with facility policy. Findings include: On 12/3/24 Staff (S) 7, the Technical Manager, provided the Association for the Advancement of Medical Instrumentation (AAMI) Chemical Analysis reports for the dates 3/13/24 and 9/12/24. Upon review, the AAMI results for 3/13/24 showed no results and was marked “rejected.” During an interview on 12/3/24 at 1:00 PM, S7 confirmed the AAMI results for 3/13/24 were missing and that AAMI tests needs to be performed twice a year. S7 explained the water samples had been sent out on 3/13/24, but provided an email indicating that the lab equipment used to test the chemical analysis at that time was down, preventing the test from being performed. When asked when he/she looks for results after sending out water samples to the lab (laboratory), S7 stated he/she usually checks for the results in a week. S7 explained the AAMI chemical analysis should have been repeated once the laboratory equipment was operational again but stated he/she only noticed it today while preparing the documents for the surveyor. S7 stated it was his/her mistake and the missing results were not entered into QAPI (Quality Assurance Performance Improvement). A review of facility policy titled, “Non-patient Lab Requirements” date issued 01//18/2016, stated, “... Policy: ... 9. Twice a year in February and August, perform an AAMI water analysis from the RO product water and the RO distribution loop return ...” N.J.A.C 8:43A-24.10(a)(2)”

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 48966 Based on review of nine records of the Acid Concentrate Batch Mix and Transfer Log records for the dry acid that is mixed at the facility, review of facility documents, staff interviews and review of facility policy, it was determined that the facility failed to ensure that: 1) documentation contains specific gravity in one of the nine records; and 2) a second staff member verifies the responsible technician transferring the acid into the storage tank in nine of the nine records. Findings include: A review of the “Acid Concentrate Batch Mix and Transfer Log” records revealed the following: 1. On 11/27/24, the log lacked documentation of the specific gravity for the 3K (potassium) 2.5 Ca (calcium) acid that was mixed. 2. On 11/1/24, 11/4/24, 11/5/24, 11/11/24, 11/14/24, 11/18/24, 11/22/24, 11/25/24 and 11/27/24, the transfer of acid portion of the logs lacked a verifying person different than the technician transferring the acid into the storage tank. On 12/3/24 at 1:59 PM, Staff (S) 7, the Technical Manager confirmed that all areas of the “Acid Concentrate Batch Mix and Transfer Log” need to be filled out including the specific gravity. S7 stated that Biomed (Biomedical Technician) makes the acid, transfers, and verifies the acid batch that is transferred into the storage tank. S7 was unsure if a second person needed to verify the acid transfer into the storage tank. On 12/4/24 at 9:26 AM, S8, the Interim Educator, confirmed that in addition to the responsible technician, a second staff member has to verify the transferring of acid. Facility policy titled, “Acid Concentrate Mixing, Transferring, and Rinsing of the Fresenius Dissolution Unit(Granuflo) Mixer,” date issued: 03/15/2023, stated, “... Policy: ... 7. The following documentation requirements for mixing acid concentrate will be recorded on the Acid Concentrate Batch Mix and transfer log as the steps are completed ... [bullet] specific gravity reading from a hydrometer ... [bullet] Transfer verification of mixed concentrate to appropriate storage tank ... Preparation for Dissolution Cycle ...15. Test the solution with a hydrometer to verify Specific Gravity is with the set limits indicated in Table 1. 16. Document the test results on the Acid Concentrate Batch Mix Log ... Transfer to Storage Tank 1. Documents the date and time of the transfer on the Acid Concentrate Batch Mix and transfer Log ... 6. Document the Tank Identification information on the Acid Concentrate Batch Mix and Transfer Log with the initials of both the responsible technician and verifying person ...” N.J.A.C 8:43A-24.10(a)(5)”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 51040 Based on observation and staff interview on 12/4/24, it was determined that the facility failed to ensure that surfaces within the dialysis facility are cleaned and maintained. Findings include: During a tour of the facility beginning at 9:55 AM, in the presence of Staff (S) 7, the Biomedical Technician, the following was observed: -In the CAPD (Continuous Ambulatory Peritoneal Dialysis) Training Room, there was damage to the wall near the exterior window lower corner of about 4 square inches. -At Station 19, the hinges and screws on the shelf of the tubing chase had a brownish-red residue. -At Station 10, the wall covering was coming off and the emergency electrical outlet was loose from the wall. -At Station 11, there was wall damage at the lower left corner of about 4 square inches. -At Station 12, a 4” x 6” area of the outer left wall of the doorway was damaged. -In the Medical Waste Room, there was a 5 foot by 2 foot damaged area of the wall below the window. S7 confirmed the above findings. N.J.A.C. 8:43A-17.3(j)”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48966 Based on review of facility documents and staff interviews, it was determined that the facility failed to ensure that: 1) the hemodialysis machine is disinfected and documented in accordance with the facility policy for 14 of 14 hemodialysis machines; and 2) three of three Myron L D6 meters (used to check the conductivity and pH [potential of hydrogen] to ensure quality and safety of the dialysate before it is used in dialysis treatment of patients) are checked and calibrated prior to daily use. Findings include: 1. A review of the “Fresenius 2008T Disinfection Logs” for the 14 hemodialysis machines for the month of November 2024, revealed that the log lacked documented evidence that on 11/12/24, 11/14/24 and 11/24/24 all 14 hemodialysis machines were disinfected. During an interview on 12/4/24 at 9:54 AM, Staff (S) 1, the Nurse Manager confirmed to missing data on the above dates. S1 explained that the logs need to be filled out everyday including the back-up machines. Facility policy titled, “Disinfection Of The Fresenius T/t=TBlueStar Machine,” date issued 01/17/2024, stated, “ ... Procedure: Citric Acid (Vinegar) Rinse ... a. Daily citric acid rinse is necessary to prevent buildup of bicarbonate precipitate and machine malfunction ... Heat Disinfection 1. After completion of acid rinse, select Heat Disinfect from main menu and press confirm ... 2. Document on the disinfection log sheet for that machine ...” 2. A review of the “Daily Myron L D-6 Log” for the months of October 2024 and November 2024 revealed that all three meters were not checked and calibrated on the following days: 10/12/24, 10/14/24, 10/18/24, 10/30/24, 11/8/24, 11/20/24, 11/22/24, 11/23/24 and 11/24/24. During an interview on 12/4/24 at 10:16 AM, S1, the Nurse Manager, confirmed the above mentioned dates had not been filled in and the ‘Daily Myron L D-6 Logs’ needed to be completed daily. Facility policy titled, “Myron L D6 Meter Disinfection, Calibration, Use and Storage,” date issued 6/24/2021, stated, “... Policy: 1. The meter will be verified against 14.0 mS [microSiemens per meter] conductivity and 7.0 pH standard solutions daily prior to use, and/or whenever inaccurate readings ARE SUSPECTED OR DOCUMENTED ON THE “Daily Dialysate Meter log” sheet ...” N.J.A.C 8:43A-24.11(c)”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51227 Based on one of one observation of initiation of hemodialysis through an Arteriovenous Fistula (AVF, a type of access used for hemodialysis), staff interview, and a review of facility documentation, it was determined that the facility failed to ensure that staff perform proper skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 12/3/24 at 11:40 AM, in Station 9, Staff (S) 3, a Patient Care Technician (PCT), initiated hemodialysis through an AVF. S3 cleansed the first site of the AVF with one alcohol preparation (prep) pad in a circular motion for 20 seconds and then cleansed the second site with one alcohol prep pad in a circular motion for 15 seconds. S3 did not clean the exit site for one minute and did not use three alcohol prep pads to cleanse the site per facility policy. During an interview at 12:00 PM, S3 explained the procedure for cleansing the site of an AVF. He/she said to cleanse the site with an alcohol prep pad for 15 seconds for each site. Facility policy titled, “Preparation And Cannulation of Arteriovenous Graft (AVG),” last revised August 2024, stated, “ ... Procedure: ...7. ... Option #2 70% Isopropyl alcohol (should only be used if patient is allergic to betadine or chlorhexidine). With clean, gloved hands, clean cannulation site with 70% alcohol/alcohol prep-pad. Start in the center of the cannulation site working from the inside, outwards in a concentric circular pattern. Repeat these steps with a minimum of 3 alcohol prep-pads per site (20 seconds per pad) for a total contact time of 1 minute. Repeat steps for second cannulation site. Proceed with cannulation while alcohol is wet ...” N.J.A.C. 8:43A-24.4(a)”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 50912 Based on observation, staff interview, and review of instructions for use, it was determined that the facility failed to ensure that a bottle of LiquaCel is not available for use beyond the expiration date. Findings include: On 12/3/24 at 10:58 AM, during an observation of the medication preparation area, a quarter- full bottle of LiquaCel (a medical food/ protein supplement) with clear liquid solution was found inside the top cabinet on the right side of clean sink. The bottle was labeled with an opening date of 08/29/24, timed 9 AM and with the signature of a staff member written on the bottle. Upon interview at 11:05 AM, Staff (S) 2, Charge Nurse, stated that the LiquaCel expires after 90 days of opening. This bottle was kept available six days beyond the 90 day expiration date. S2 then proceeded to discard the expired bottle of LiquaCel in the waste container. Review of the LiquaCel product instructions for use and consumption states, “... Storage: may or may not be refrigerated. Do not use if safety seal is broken. Be sure to date when first opened. Use with in three months of opening ...””