UNC Lenoir Health Care

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 40299 Based on facility policy and procedures, observations, and staff interviews, the facility staff failed to ensure with infection control program requirements by failing to clean and high level disinfect per facility policy and American National Standards for 3 of 3 specialty scopes and for failing to reprocess endoscopes hanging past the expiration date for 7 of 9 endoscopes that were hanging in the clean endoscope cabinets. The findings include: 1. Review on 02/26/2025 of the facility policy titled “Cleaning, Disinfection and Sterilization of Equipment & (and) Environment” last reviewed on 10/14/2024 revealed “Definitions ... 2. Cleaning - The physical removal of all visible soil and organic material from objects, usually done with water with detergents or enzymatic products. Meticulous (showing great attention to detail) cleaning must precede disinfection and sterilization procedures, since materials that remain on the surfaces of instruments interfere with the effectiveness of these processes. 3. Decontamination - a procedure that removes or inactivates pathogenic microorganisms (tiny bacteria or fungi too small to see with naked eye) on objects so that they are safe to handle. 4. Disinfection - Disinfection means the use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms (organism that causes disease) but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects. There are three levels of disinfection: high, intermediate, and low. High-level disinfection kills all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleared from marketing as a sterilant by the Food and Drug Administration. Intermediate-level disinfection kills mycobacteria (bacteria with waxy cell wall), most viruses, and bacteria with a chemical germicide registered as a ‘tuberculocide (substance or process that disables or destroys bacteria)’ by the Environmental Protection Agency (EPA). Low-level disinfection kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA. 5. Spaulding classification - A strategy for reprocessing contaminated medical devices. The system classifies a medical device as critical, semicritical, or noncritical on the basis of risk to patient safety from contamination on a device. The system also established three levels of germicidal activity (sterilization, high-level disinfection, and low-level disinfection) for strategies with the three classes of medical devices (critical, semicritical, and noncritical). ... Device Classification ... Semicritical-contact mucous membranes or no-intact skin ... Examples: ... Endoscopes, ... etc. ... Spaulding Process Classification ... High level disinfection ... EPA Product Classification ... Sterilant/disinfectant ... 6. High-Level Disinfections - A process that eliminates all pathogenic microorganisms on inanimate objects with the exception of high numbers of bacterial endospores. Several factors influence the effectiveness of disinfection, including (1) the presence of organic matter, (2) proper choice of disinfectant for the object to be disinfected and (3) the concentration and exposure time of the disinfectant solution. Meticulous cleaning is required prior to immersion in disinfectant. ... General Guidelines for Use of Disinfectants: ... 5. Semicritical devices such as rectal probes, vaginal probes and cryosurgical probes can be cleaned with high-level disinfection with a non-toxic product. Use of probe covers/condoms over the instrument is encouraged but still requires the above cleaning procedures. ... 12. Always follow manufacturer’s instructions for disinfectant contact time (how long the disinfectant should be wet or undisturbed on the surface to allow disinfectant to kill microorganisms effectively) for any hospital approved disinfectant. Use only hospital approved disinfectants. Management of Clean Equipment and Sterile Supplies ... 5. Semi-critical equipment, those touching mucous membranes, such as laryngoscopes, endoscopes, respiratory care and anesthesia equipment require high level disinfection according to the manufacturer’s recommendations before re-use. ...” Review of the Manufacturer’s Recommendations for the “Rectal Probe” revealed Chapter 2 Probe Processing Procedures ... Probe Processing To prevent transmission of disease, adequate cleaning and disinfection are necessary before first use, between patient use, and every time the probe is stored or transported in a non-clean container like shipping case. All probes must be thoroughly cleaned prior to disinfection. ... Table 2-1 * Care Methods by type of tissue ... Type of tissue ... Mucosal or Non-intact skin ... Care Method ... Cleaning followed by High-Level Disinfection (HLD) (soaking or wipe or use of a Trophon EPR or Trophon 2) ... Table 2-3 * Products with validated efficacy performed by GE HealthCare ... Product Type ... High-level Disinfectant (Soak) ... Trade Name ... Cidex OPA (FDA cleared) ... Manufacturer ... Advanced Sterilization Products (J&J) ... Minimum Contact Time ... 12-Minute Soak ... Active Ingredient ... Ortho-phthalaldehyde ... Probe Manual Cleaning ... Probe High-Level Disinfection (HLD) High-Level Disinfection is required for devices that contact intact mucosal membranes or non-intact skin. High Level Disinfection can be performed using either disinfecting wipes (only for some probes), a disinfectant soaking method or an automated system ... Probe HLD - Soak 1. Ensure the probe has been disconnected from the console. Use necessary precautions (e.g. gloves, face screen and gown), as directed by your facility and fill a sink or basin with High-Level Disinfectant prepared in accordance with the disinfectant manufacturer’s instructions to a level allowing immersion of the probe up to immersion line shown in the system user manual ... 2. Immerse probe in the disinfectant up to the immersion line shown in the system user manual and ensure no air bubbles are trapped on probe’s surface. Ensure the probe remains in the disinfectant for at least the minimum contact time ... 3. Thoroughly rinse the probe by immersing it in a large volume of Critical Water for a minimum of 1 (one) minute. Remove the probe and discard the rinse water. Repeat rinsing two additional times, for a total of 3 (three) rinses. Do not reuse the water. Always use fresh volumes of water for each rinse. ... 4. Thoroughly dry all surfaces of the probe using a soft, low-/non-linting wipe or cloth, changing wipes/cloths when necessary to ensure the probe is completely dry. ... 5. If the probe is not immediately reused, store the probe in a manner that will protect and keep the probe from being recontaminated. ...” Review on 02/26/2025 of the facility policy titled “Transesophageal Echocardiogram (TEE) Probe Cleaning” last reviewed on 07/04/2023 revealed “... Procedure: * Immediately after use the TEE probe will be wiped down using Super Sani (sanitizer) Cloths * ‘Dirty’ probe will be sent to the Sterile Processing Department in lined container with red cover * The Sterile Processing Department will high level disinfect the probe per manufacture guidelines * Probes are stored in the Sterile Processing Department in the TEE cabinet * Technician will notify Sterile Processing department as soon as possible when a TEE has been ordered to ensure scope is ready for use *If multiple studies are to be done in the same day, Sterile Processing will be notified as early as possible and scopes will be cleaned ‘STAT’.” Review on 02/26/2025 of the facility policy titled “Speech Scope Process” last reviewed 05/04/2022 “... Procedure: 1. Prior to a procedure, speech therapy staff will notify the SPD (sterile processing department) a day prior or the morning of use. 2. Scope is placed in a lined transport tray covered with a green bag and lid. 3. SPD will notify speech therapy the scope is ready for use. 4. After use: 1. SPU (sterile processing unit) will wipe down the scope at the point of use with facility approved enzymatic cleaner. a. Place scope in the lined transport tray covered with a red bag and lid for transport. b. Notify SPD prior to transporting contaminated scope to the OR (operating room) for High Level Disinfection (HLD). 5. SPD will obtain contaminated scope to transport to the decontamination room. 1. Contaminated scope will be placed in sink with enzymatic cleaner for 10 minutes. 2. Handwash, rinse, and replace scope in transport tray and transport to HLD location. 6. Follow the Cidex OPA Test Policy. 7. Dry scope with a lint free cloth and replace in appropriate container and/or location.” Review of the “American National Standard ANSI/AAMI ST91:2021 Flexible and semi-rigid endoscope processing in health care facilities” approved by AAMI on 10/01/2021 revealed “ ... r) If endoscope is transported to patient care room but not used, it shall be processed again prior to next patient use. ... 11.2 Storage of high-level disinfected or liquid chemically sterilized endoscopes 11.2.1 Storage procedures ... All critical devices (e.g., uretoscopes, bronchoscopes) not used immediately should be processed again before use. Endoscopes should not be left in the AER basin for extended amounts of time (e.g. more than one hour), otherwise the endoscope should be reprocessed through high level disinfection/liquid chemical sterilization process prior to storage or immediate clinical use. This section provides available information that can be used by health care facilities to determine maximum storage time. ... 11.2.2 Storage cabinets ... Endoscopes processed with HLD or LCS should be stored in a cabinet that is of sufficient height, width, and depth to allow flexible endoscopes to hang vertically without coiling and without any components touching the bottom of the cabinet, or the cabinet should be designed and intended by the manufacturer for horizontal storage of flexible endoscopes ... 11.2.4.1 General considerations The accepted maximum safe storage time (previously referred to as “hang time’ or shelf life) for processed endoscopes before they can no longer be considered safe for patient use is not well defined. There are a limited number of studies addressing this issue. The available data suggest that the risk of contamination is reduced when storage is performed according to the endoscope and storage cabinet manufacturers’ written IFU. Multiple studies support the concept of viable but non-culturable cells that persist through disinfection and remain following extended storage ... If bioburden is not eliminated prior to storage, it may become more resilient over time and continue to grow, especially if the endoscopes are stored before being completely dry ...” Observation during tour of the Sterile Processing Department (SPD) Scope room on 02/26/2023 at 1047 revealed 3 of 3 scopes (identified as TEE scope, Rectal scope, and Speech scope) in transport containers with lids sitting on right side of room as entered the room. Two of the three containers had patient labels inside the container with the scopes indicating the person the scope was last used on. The scope nor the container was labeled or marked as not having completed the cleaning process which included high level disinfecting (HLD). Interview on 02/26/2025 at 1047 with Registered Nurse (RN) #1 in Central Sterile Processing revealed the three scopes in the transport trays, two of which that had patient labels under the white paper and scope, were cleaned but not high level disinfected. Interview revealed the scopes were not HLD until they were called for or scheduled to be used. Once the call occurred or scope was scheduled to be used the scope is HLD. The scopes are stored in the containers in the clean scope room until they are needed. Interview revealed this process has been in place an unknown amount of time and for as long as RN #1 could remember. Follow up interview on 02/28/2025 at 1216 with RN #1 revealed if the Rectal Probe was scheduled to be used on a patient, the scope would be high level disinfected the day prior. RN #1 would validate the dates on the Cidex, perform a strip test for 90 seconds and validate a purple pass which means the Cidex is still good. The probe is taken from the clean storage room into the soiled room where it is placed in the high-level disinfectant for 12 minutes (a timer is used each time). Once the 12 minutes are up the probe is removed from the Cidex and placed in the water for 1 (one) minute. At the end of the minute the probe is removed and the water discarded, and new water added. The probe is placed in the water again for another minute. The water is discarded and replaced a second time with the probe placed in it for another minute. (total of 3 minutes each time for 1 minute each in clean water). The tray is wiped clean with a sani wipe, and the scope is dried with a lint-free towel and placed in the tray. A clear line is placed in the tray and the scope is placed in the tray with a green liner form saying the HLD has been performed, and the clear top is put in place covering the scope. The same process happens with the Speech scope. It is placed in the Cidex for 12 minutes and in rinse water three times for one-minute intervals and the water replaced after each minute. The TEE scope does have to have a leak test prior to being put in the Cidex, this is typically done with the initial cleaning process. Interview with RN #2, the Infection Prevention Nurse on 02/28/2025 at 1315 revealed “anything can grow the longer it is allowed to sit there without the process being complete which would include the HLD. Interview follow up at 1732 revealed RN #2 did not support the practice of not completing the cleaning process of the scopes. The practice being done does not follow the manufacturer’s guidelines for cleaning the scopes (TEE and Speech scopes). The interview revealed micro-organisms can potentially grow and increase the risk for patient would be increased, cross contamination, and infection in a patient. 2. Review on 02/26/2025 of the facility policy titled “Endoscope Reprocessing Procedure” last revised 01/06/2025 revealed “... Labeling and Storage ... *Hang endoscopes vertically in a ventilated area so as not to touch each other. ... * Documentation of disinfection cycles is maintained for each patient in the daily scope log. * Scopes will be labeled with ‘CLEAN SCOPE’ label signifying the scope was properly disinfected and ready for use. ... * Scopes will be reprocessed every five days. ...” Review of the “American National Standard ANSI/AAMI ST91: 2021 Flexible and semi-rigid endoscope processing in health care facilities” approved by AAMI on 10/01/2021 revealed “... r) If endoscope is transported to patient care room but not used, it shall be processed again prior to next patient use. ... 11.2 Storage of high-level disinfected or liquid chemically sterilized endoscopes 11.2.1 Storage procedures ... All critical devices (e.g., uretoscopes, bronchoscopes) not used immediately should be processed again before use. Endoscopes should not be left in the AER basin for extended amounts of time (e.g. more than one hour), otherwise the endoscope should be reprocessed through high level disinfection/liquid chemical sterilization process prior to storage or immediate clinical use. This section provides available information that can be used by health care facilities to determine maximum storage time. ... 11.2.2 Storage cabinets ... Endoscopes processed with HLD or LCS should be stored in a cabinet that is of sufficient height, width, and depth to allow flexible endoscopes to hang vertically without coiling and without any components touching the bottom of the cabinet, or the cabinet should be designed and intended by the manufacturer for horizontal storage of flexible endoscopes ... 11.2.4.1 General considerations The accepted maximum safe storage time (previously referred to as “hang time’ or shelf life) for processed endoscopes before they can no longer be considered safe for patient use is not well defined. There are a limited number of studies addressing this issue. The available data suggest that the risk of contamination is reduced when storage is performed according to the endoscope and storage cabinet manufacturers’ written IFU. Multiple studies support the concept of viable but non-culturable cells that persist through disinfection and remain following extended storage ... If bioburden is not eliminated prior to storage, it may become more resilient over time and continue to grow, especially if the endoscopes are stored before being completely dry ...” Observation during tour of the Sterile Processing Department (SPD) Scope room on 02/26/2023 at 1047 revealed 7 of 9 endoscopes hanging in the tower past the date of hang time (greater than 5 days per policy). The scopes were observed with “expired” written in black ink on the scope tag and expiration dates of 02/18/2025, 02/19/2025, 02/23/2025 and 02/25/2025. Two additional scopes would expire at the end of business day (02/26/2025). Interview on 02/26/2025 at 1047 with Registered Nurse (RN) #1 in Central Sterile Processing revealed the tags on the scopes were marked when they expire. The scopes would not be used and the scopes that were out of the hang time would be reprocessed prior to being used. The interview revealed the scopes are not used everyday and they are scheduled for use so the scope can be reprocessed prior to anyone taking it. Interview on 02/28/2025 at 1315 with RN #2, Infection Control nurse, revealed the scopes should be reprocessed per policy. Interview revealed RN #2 had not performed observations in the central sterile department since 2023. Interview revealed RN #2 planned to spend time with IC #3 in the SPD department. NC00221078; NC00223025; NC00227494”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 50111 Based on review of policy, personnel files, job descriptions and staff interview, the facility failed to ensure current certification was maintained in Basic Cardiac Life Support (BCLS) for 1 of 3 Certified Nursing Assistant (CNA) personnel files reviewed requiring BCLS certification according to the job description (CNA#4). The findings include: Review of 08/02/2024 of hospital policy “Staff Competency Assessment,” effective 09/11/2020, revealed, “... 5. Employees required by their job description to have CPR certification must maintain current certification through the American Heart Association. ... 13. Departmental leadership is responsible for ensuring that all competency requirements are met. ...” Review on 08/02/2024 of CNA#4’s personnel file revealed CNA#4 was employed from 11/08/1999 until 04/14/2023. Review of CNA#4’s BCLS certification revealed the certification expired on 03/31/2023. Review failed to reveal documentation of BCLS certification renewal after 03/31/2023. Review on 08/02/2024 of the Job Description for CNA#4 revealed BCLS certification was listed as a requirement under the “Licensure/Registration/Certification” section of the “Job Specifications.” Review revealed the Job Description was signed on 09/07/2022 by Nurse Supervisor#5 and was signed on 09/28/2022 by CNA#4. Review on 08/02/2024 of the Staffing Schedule revealed CNA#4 worked the following dates in April 2023: on 04/03/2023 as a Monitor Tech (Technician), on 04/06/2023 as a CNA, on 04/09/2023 as a CNA, and on 04/11/2023 as a Monitor Tech (4 of 14 days employed in April 2023). Review revealed CNA#4 worked 2 of the 4 scheduled shifts in direct patient care. Interview on 08/02/2024 at 1150 with the Vice President of Nursing (VPN#6) confirmed CNA#4 had no updated BCLS certification on file after 03/31/2023. Interview revealed nursing leadership was unaware of the expired certification due to a change in the department leadership at that time. Interview revealed department leaders were responsible for ensuring BCLS certification was maintained for each employee.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38766 Based on hospital policy reviews, medical record review, safety event review, and staff interviews, the hospital failed to ensure a patient with signs and symptoms of a stroke had a CT/CTA (Computed Tomography/Computed tomography angiography) performed per facility policy in 1 (one) of 1 (one) stroke patient chart review (Patient #2). The findings include: A review on 07/31/2024 of the hospital’s policy “Care of Patient Presenting to the ED (Emergency Department) with Acute Stroke Symptoms” effective 07/01/2021 revealed “Purpose: To facilitate the care of patients who develop stroke-like symptoms, using best practice guidelines, efficient diagnosis and timely intervention... Procedure: A. Stroke response ...4. Nursing will facilitate the following: Facilitate transport to CT for a non-contrast head CT (STAT) [urgently]...” A review on 07/31/2024 of the hospital’s policy “Radiology Orders Status Policy and Procedures” effective 04/21/2014 revealed “...Procedure: III. All STAT in-house, ED, or outpatient procedures will take priority over routine and scheduled procedures and be done immediately...” A review on 07/31/2024 of Patient #2’s medical record revealed a 71-year-old male presented to the emergency department on 02/09/2023 at 1426 via Emergency Medical Services (EMS) with complaints of episodes of aphasia (difficulty with speech) and left-sided weakness. The review revealed Patient #2 reported to his primary care provider (PCP) who called EMS for stroke-like symptoms. The review revealed Patient #3 reported an episode 2 to 3 days ago where the entire left side of his body felt weaker than the right and had issues with his grip at the time of ambulation. The Patient Care Timeline revealed the initial triage was completed at 1515 and the medical screening exam (MSE) was done at 1626. The record review revealed the ED provider ordered a STAT CTA of the head and neck with contrast on 02/09/2023 at 1652 and a routine CT of the head without contrast at 1653. The review revealed the CT of the head without contrast was completed at 2013 (5 hours and 27 minutes after arrival and 3 hours and 20 minutes after the order was written). The CTA was completed at 2014 (5 hours and 28 minutes after the patient’s arrival and 3 hours and 22 minutes after the order was written). The record review revealed that the staff failed to complete a CT and CTA for Patient #2 per the hospital policy. A review on 07/31/2024 of a safety event reported on 02/10/2023 revealed Patient #2 arrived at the ED with neurological stroke-like symptoms at 1426, a STAT CT/CTA was ordered at 1653, and was completed at 2013. The review revealed, “in the setting of an acute stroke, CPG (Clinical Practice Guideline) call for imaging regardless of lab values...” The safety report revealed the policy was not followed. An interview on 08/01/2024 at 1045 with the Stroke Coordinator revealed that based on the symptoms reported by the patient, the last known well would have precluded the patient from being a code stroke but the CT/CTA should have been done in a more expedited manner. An interview on 08/01/2024 at 1115 with the ED Director revealed that Patient #2 was an acuity level 3 and did not fall into the code stroke protocol. The interview revealed that the Director did review the safety report from the ED perspective and the almost 6 hours wait time between arrival to the ED to the completion of the CT/CTA was not ideal and the policy was not followed.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by other practitioners, not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 51294 Based on policy review, medical record review and staff interview the hospital staff failed to follow policy and procedure to monitor a patient during a blood transfusion for 1 of 2 (Pt. # 17) sampled blood transfusion records reviewed. Findings include: Review on 07/31/2024 of the hospital policy “Blood and Blood Product Administration” - PolicyStat ID 15201953, last revised 02/13/2024, revealed “B.8...Obtain baseline VS (vital signs) 15 minutes prior to picking up blood ...B.17. Obtain and record vital signs 5 minutes after initiation ... stay with the patient for the first 15 minutes after the blood reaches the angiocath ...19. Obtain and record vital signs 30 minutes after initiation of blood product and as needed on the Blood Admin flowsheet in the EHR (electronic medical record) ... Observe the patient closely every 30 minutes, along with a set of vital signs during the remainder of the transfusion, for any signs and symptoms of transfusion reaction ...20. Obtain and record the vital signs upon completion ...” Review of the closed medical record for Patient #17 on 08/01/2024 revealed a 69-year-old female that presented to the Emergency Department on 07/17/2024 and was admitted with a chief complaint of shortness of breath. Review of the medical record revealed Patient #17 received orders on 07/19/2024 to transfuse 2 units of Packed Red Blood Cells (PRBCs). Review of the blood transfusion nursing notes revealed Patient #17 received one (1) of the two (2) units of PRBCs from 1633 to 1922. Review of the nursing documentation revealed the first unit was completed at 1922 and the attending physician was notified of a possible transfusion reaction. The order to transfuse the 2nd unit of PRBC’s was discontinued. Vitals signs were documented at 1536, 1630, 1638 (no BP), 1648 and 1922. Review of the medical record failed to reveal documentation of every 30 minutes vital signs from initiation to completion of blood transfusion. Interview on 08/02/2024 at 1230 with RN #3 (with Manager of Inpatient Services present) revealed she was the nurse that administered the blood to Patient #17 on 07/19/2024, interview revealed there were no documented vitals signs between 1648 and 1922 (2 hours and 34 minutes). The nurse manager asked “Did you have her on the vital sign machine?” and RN # 1 stated “I ’ ll be honest, no”. Interview revealed the staff failed to follow the hospital policy.”

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 34065 Based on review of job description, observations, review of personnel files, and interviews with staff, the hospital failed to ensure staff was knowledgeable and competent to perform dishwashing tasks for 1 of 1 personnel files reviewed. The findings include: Review of the job description titled “FOOD SERVICE ASSOCIATE” dated 03/15/2022 revealed “Job Purpose: The Food Service Associate may work anywhere on property where food is prepared...General Responsibilities: v. May perform other duties and responsibilities as assigned.” Observation on 08/01/2024 at approximately 1120 revealed Dishwasher #12 was standing at the compartment sinks with thin layer of bubbles in the filled sinks of water. Interview on 08/01/2024 at approximately 1130 with Dishwasher #12 revealed Dishwasher #12 was assigned to wash dishes on 08/01/2024. Dishwasher #12 was unable to demonstrate correct water level, amount of soap to be added to the water and use of pH test strips. (Chemical strips to determine correct balance of soap in the water). Interview revealed Dishwasher #12 stated he “was not trained to wash dishes.” Review of the personnel file for Dishwasher #12 revealed a hire date of 02/06/2023 with no documentation of a dishwashing competency. Interview on 08/01/2024 at 1140 with the Director of Nutrition Services #13 revealed Dishwasher #12 was trained for stock room; but was moved to dishwasher. Interview revealed Dishwasher #12 is a utility worker, which includes dishwashing.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 34065 Based on observations, review of policies, interviews with staff, the dietary staff failed to date and label open containers of food and failed to document daily calibration of food thermometers on the thermometer calibration log. The findings include: 1. Observation on 08/01/2024 at 1050 revealed an opened bag of Basmati Rice wrapped in cellophane sitting on the storage shelf with no opened date. Observation revealed an opened box of Cream of Wheat with no opened date or expiration date. Observation revealed a plastic tub of granola with lid partially off of the tub with no expiration date. Observation revealed a box of opened baking soda sitting in a plastic sandwich bag with expiration date of 10/16/2025, 14 months later.” Review on 08/01/2024 of the “(Dietary Contract Name) Food Safety Management System” with a revision date of 01/28/2022 revealed “Rice, flavored or herb” with dry storage date of 6 months. Keep tightly closed after opening...Grits with dry storage date of 12 months and store in airtight container after opening. Cereals, ready-to-eat with dry storage of 6-12 months. Refold Package liner tightly after opening....Baking soda with shelf life of 6 months opened.” Review on 08/01/2024 of the policy titled “Food Storage” with revision dated of 06/18/2024 revealed “...Procedure: 1. The Receiving Clerk is responsible for storage of food and non-food items. 2. Foods are regularly inspected for signs of damage due to spoilage...4. Stock is rotated to support use of a ‘First-In, first-Out (FIFO) approach....7. Products are labeled and dated per (Dietary Contract Name) and regulatory standards....All Foods: Must be in food grade containers. Dry Bulk Foods: Store in non-reactive metal or plastic containers with tight fitting lids.” Interview on 08/01/2024 at 1245 with Director #13 revealed the bag of rice, cream of wheat and granola did not have a date and should have been dated. The interview revealed the rice, cream of wheat and granola should have been in airtight containers. The interview revealed the baking soda was incorrectly dated. The baking soda should have been dated only 6 months from opened date. Interview revealed all of these food items have been discarded. Interview revealed the safety date policy had not been followed. 2. Review on 08/01/2024 of the procedure titled “Thermometer Calibration Log” dated 3-10-2023 revealed “Instructions: 1. Use this log to document the accuracy checks of the operation’s food thermometers that are in use. 2. Check the accuracy of all in use food thermometers daily. 3. Calibrate thermometer using one of the following calibrations procedures: 3.1. Ice Point Method (if thermometer will be used for refrigerated product): 32F (Fahrenheit) (+/-2F) or 0C (+/-0.5C). 3.2. Boiling Water Point Method (if thermometer will be used for hot product items...4. Discard/replace thermometers that do not meet the calibration requirements. 5. Manager must review log within seven days.” Review of the log titled “Thermometer Calibration Log” revealed 3 entries for 07/18. Review revealed no other entries for the days of the month. Review revealed the first entry was titled “(Name)” thermometer in the Thermometer ID column with results of 32.3 actual temperature reading. The word “Ice” was handwritten in the column of Target Temperature Reading. Review revealed the second entry for 07/18 reads “front line” and 32 as actual temperature. The third and final entry on the log revealed “07/18” with “Cook’s” thermometer and “32.2” actual temperature reading. The line on the bottom of the log read “Reviewed by: Manager or Person-in-charge” remains blank and without a signature. Interview on 08/02/2024 at 0945 with Director #13 revealed there were no more temperature logs available. Interview confirmed the logs were incomplete and should have been completed. NC00186552; NC00194338; NC00199408; NC00210532; NC00211225; NC00214434”