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Based on record review and interview, the facility failed to ensure that dietary staff (S) were competent in their duties and failed to include documentation of competency in the employee files for 5 (S8, S9, S10, S13, S14) out of 10 (S5 through S15) staff (s) files reviewed. This failed practice is likely to cause ineffective practices and low standards care.

The finding are:

A. Record review of 5 out of 10 employee files revealed no verification of department specific training regarding the duties for dietary staff after hire.

1. On 08/25/2021, record review of S8 (Cook) hired 06/14/2010, employee file revealed no documentation or verification of department specific training regarding education for the specific duties as a cook after hire.

2. On 08/25/2021, record review of S9 (Cook) hired 08/08/2016, employee file revealed no documentation or verification of department specific training regarding education for the specific duties as a cook after hire.

3. On 08/25/2021, record review of S10 (Cook) hired 12/26/2012, employee file revealed no documentation or verification of department specific training regarding education for the specific duties as a cook after hire.

4. On 08/25/2021, record review of S13 (Cook) hired 07/19/2011, employee file revealed no documentation or verification of department specific training regarding education for the specific duties as a cook after hire.

5. On 08/25/2021, record review of S14 (Cook) hired 02/05/2018, employee file revealed no documentation or verification of department specific training regarding education for the specific duties as a cook after hire.

B. On 08/25/202 at 2:15 pm, during interview with S11 (Dietary Director) confirmed the absence of documentation of the education and training given to the cooks upon hire.

Based on observations and interviews, the facility failed to adhere to the dietary based infection control program focused on preventing cross contamination (process by which bacteria, viruses, and fungi are unintentionally transferred from one substance to another) and foodborne illnesses (disease caused by consuming contaminated food or drink). This failed practice is likely to lead to an increased risk of foodborne illnesses and harm to all patients at the facility.

The findings are:

A. On 08/24/2021 at 1:30 pm, observations made during flash tour of facility's dietary department revealed:
1. 4 tubs of raw chicken breast in the walk in refrigerator with use by date of 08/23/2021. Tubs noted to have "Rec" on it, but no definition of what this means.

2. 1 tub with 4 packages of raw pork in the walk in refrigerator with use by date of 0 8/23/2021. Tub noted to have "Rec" on it, but no definition of what this means.

3. 1 carton of Half and Half in refrigerator with an expiration date of 07/25/2021.

4. 5 gallons of milk with an expiration date of 08/21/2021

5. Open vegetable tamales in the walk in freezer with visible signs of freezer burn ( a condition of discoloration or other damage caused to frozen food by evaporation, typically due to inadequate packaging or storage conditions in the freeze).

6. One opened box of green beans in the walk in freezer not covered to protect from freezer burn.

7. 2 pans of lasagna in the walk in freezer with damaged covers and evidence of freezer burn.

B. On 08/24/2021 at 1:45 pm, interview with S (staff) 11 (Dietary Director) reported that the "Rec" most likely represents when the product was received, pulled from the freezer to be thawed and used. S11 confirmed that the tubs of raw products with "Rec" on them and a postdated use by date can lead to confusion in determining if the product is expired or not. For items 3 through 7 on evidence A, S11 endorsed that those products shall not be used as they are not fit to serve. S11 confirmed that the facility does not utilize a tracking log to ensure that expired or damaged products do not remain in the refrigerators or freezers.