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Based on review of policy and procedure, observations, departmental logs and staff interview the staff failed to ensure the Cooling.Chilling Temperature was as per policy, Weekly High Temperature Mechanical Ware Washing Machine was maintained as intended daily and the Sanitizer Solution Dispenser was maintained as per policy.

Findings included:

Review on 04/23/2025 of the hospital policy and procedure for HACCP - COOLING/CHILLING TEMPERATURE LOG revision date, 08/15/2022 revealed "Instructions: Use this log to record cooked time/temperature controlled for safety food (TCS [Time/Temperature Control for Safety] food) that is cooling and prepared TCS foods that are chilling prior to service ...(2) Date: Document the date of the food being cooled/chilled (3) Food item: Document the name of the food being cooled/chilled ...(5) Time food started chilling: Document the time the food started chilling (6) Temp food started chilling: Document the temperature of the food when it started chilling ..."

1. Observation on 04/23/2025 at 0915 during tour of the hospital kitchen area Cooler 1 with the Director of Food & Dietetic Department and Executive Chef revealed a small pan covered with plastic of Macaroni & cheese without label to identify food, date or time of cooked item. Cooler 1 also revealed an uncovered pan of cooked 2 large steaks cooked without label to identify food, date or time of cooked item.

Interview on 04/23/2025 at 0915 with the Executive Chef revealed the daily supervisor was the staff member expected to validate the task completion for labeling food items in Cooler 1.

2. Observation on 04/23/2025 at 0915 during tour of the hospital kitchen area Cooler 2 with the Director of Food & Dietetic Department and Executive Chef revealed an opened container of Horseradish expiration date of 04/04/2025 with an open date of 03/04/2025 on the shelf available for use.

Interview on 04/23/2025 at 0915 with the Executive Chef revealed the daily supervisor was the staff member expected to validate the task completion for labeling food items in Cooler 2.

3. Observation on 04/23/2025 at 0915 during tour of the hospital kitchen area Cooler 3 with the Director of Food & Dietetic Department and Executive Chef revealed an opened gallon of milk without label of open date.

Interview on 04/23/2025 at 0915 with the Executive Chef revealed the daily supervisor was the staff member expected to validate the task completion for labeling food items in Cooler 3.

4. Observation on 04/23/2025 at 0915 during tour of the hospital kitchen area with the Director of Food & Dietetic Department and Executive Chef revealed the Weekly High Temperature Mechanical Ware Washing Machine Log was incomplete. The staff were expected to validate the wash temperature and final rinse temperature three times per day (breakfast, lunch and dinner). Review of the log revealed on 03/08/2025 breakfast and lunch, 03/22/2025 dinner, 03/24/2025 dinner, 03/27/2025 breakfast, lunch and dinner, 03/29/2025 lunch and dinner, 03/30/2025 dinner, 04/06/2025 dinner, 04/07/2025 dinner, 04/10/2025 breakfast and lunch, 04/11/2025 breakfast and lunch, 04/12/2025 and 04/13/2025 breakfast, lunch and dinner, 04/18/2025 dinner, and 04/20/2025 breakfast and lunch were blank for assessment of the temperature.

Interview on 04/23/2025 at 0915 with the Executive Chef revealed the daily supervisor was the staff member expected to validate the task completion for the High Temperature Mechanical Ware Washing Machine Log. The staff members failed to ensure the task was completed for each expected time and date.

5. Observation on 04/23/2025 at 0915 during tour of the hospital kitchen area with the Director of Food & Dietetic Department and Executive Chef revealed the Sanitizer Solution Dispenser Log was incomplete. The staff were expected to validate the sanitizing solution had reached an acceptable temperature above 65 degrees Fahrenheit (a measurement scale of temperature) daily. Review of the log revealed on 03/19/2025, 03/20/2025, 04/10/2025, 04/11/2025, 04/12/2025, 04/13/2025, and 04/20/2025 were blank for assessment of the temperature.

Interview on 04/23/2025 at 0915 with the Executive Chef revealed the daily supervisor was the staff member expected to validate the task completion for the Sanitizer Solution Dispenser Log. The staff members failed to ensure the task was completed for each expected time and date.

NC00227913, NC00225684