OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and correct sanitation methods followed, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: 1. Observation of the kitchen on 01/28/25at 10:00 am through 1:30 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine; * Spice shelves; * Kitchen drains; * Trash cans; * Pipes and flooring underneath the three compartment sink; * Walls throughout kitchen; * Open shelving under the steamtable holding clean dishes; * Interior and exterior of microwave; * Stove/grill/oven knobs, doors, interior, exterior; * Area around grill/stove; * Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers and around the hood; * Open shelving throughout kitchen; * Industrial can opener and housing; * Floors throughout the kitchen had black matter build-up, food and trash debris and grease in corners, under equipment, shelving and around perimeter edges; * Floors in walk in refrigerator and freezer; * Rack shelving in dry good storage; * Rack shelving storing equipment and dishes; * Floors under and behind shelving in dry good storage; * Window and surrounding area; * Ceiling and light covers with food splatters/stains; * Dish/Utility carts in kitchen and dish washing area; * Bulk dry good bins, handles and lids; * Interior of ice machine; * Steam table edges/corners and; * Dining room floors and table bases. b. The following areas were found in need of repair: * Doorway to office inside kitchen area and dry storage with scrapes/knicks and pealing/missing paint; * Plastic stripping along window seal area with chips and missing pieces; * Threshold doors to Staff 2 office and dry storage with damaged/missing paint; * Multiple light fixtures with cracks; * Walk in cooler with large ice/frost buildup in threshold to freezer; * Refrigeration fans in walk in fridge/freezer with dust build up; * Dish machine not functioning correctly with wash/rinse temperature and sanitizer levels. * Gaps or holes in the walls around pipes or electrical needing filled. d. Dish machine used at facility was a low temp/chemical sanitizing machine. After multiple cycle runs, dish machine wash and rinse cycles were not reaching a minimum of 120 degrees Fahrenheit as required. The rinse cycle was not registering any PPM of sanitizing solution. Strips utilized were for chlorine. Large amounts of foam were generated during the rinse cycle and it appeared that dish soap/detergent was dispensing in large amounts during the rise cycle, not a sanitizing chemical. Staff 2 () was notified who immediately called the vendor to service the machine. Facility switched to 3 compartment sink for sanitation until dish machine could be serviced. e. Wall dispenser for surface sanitation was producing a highly foaming product. Test strips provided for chemical were not registering in the color scheme designed for product located on test strip bottle to indicate level of concentration was adequate for sanitation. Product was a lactic acid blended compound that per manufactures specifications was safe for food and non food contact surfaces in kitchens. Staff were unaware of the green color the strip was registering and what concentration that rendered per the bottle. Staff 2 agreed he was not familiar with this chemical and that they had been using a Quat ammonia based sanitizer before and had recently changed. Facility still had some Quat chemical and switched to that sanitizing solution until chemical vendor could assess the situation with the wall dispensing unit. Surveyor tested the quat chemical and was found at the correct sanitizing strength PPM for their 3 compartment sink and surface sanitizing buckets. f. Observations during tray service found cook to not check the temperature of a grilled hamburger or boiled hot dog prior to service. No observations were made of staff checking food temperatures prior to service. Cook was able to verbalize the temperatures of the food products which were at or above appropriate cook to and hot holding temperatures. Facility did not have any food temperature logs to review to ensure/validate system of checking temperatures prior to service. All food items were at or above appropriate hot holding temperatures upon request. Staff 2 acknowledged cook to order items should be checked for appropriate cook to temperatures by cook prior to service. g. Staff 2 was observed to prepare lettuce and tomato for garnish/vegetable for grilled hamburger. No observations were made that the tomato or the green leaf lettuce were effectively washed prior to cutting and preparing for the hamburger. Staff 2 was interviewed and acknowledged that their normal practice is to wash all produce prior to any ready to eat preparation including for sandwiches and hamburger plates. Staff 2 acknowledged he did not wash the lettuce or tomato before preparing for the hamburger plate and should have. h. Multiple kitchen staff observed not utilizing facial hair restraints when cooking and/or handling clean dishes/equipment as required per rule. i. Disposable single service utensils were observed stored in the kitchen open to potential contamination with FCS (food contact surfaces) exposed and/or pointing up so that the FCS could/would be touched and potentially contaminated when handled. Preset utensils in the dining room where wrapped, however the paper napkin used to wrap the silverware was not properly covering the FCS of the utensils still exposing them to potential contamination. j. Multiple racks used for washing dishes observed stored on the floor. At approximately 12:45 pm surveyor reviewed above areas with staff 2 (Dining Service Manager. Staff 2 acknowledged the areas and assured surveyor they would be addressed. At approximately 1:00 pm the areas of concern were reviewed with Staff 1 (Executive Director) who acknowledged the identified concerns.

A. The food spills/splatters, trash and loose food were cleaned on the date of the visit (1/28/2025) and have been maintained daily since then.The DSM plans to maintain a regular cleaning checklist to prevent accumulation of dirt, dust and grease. On 2/15/25, the Kitchen will be closed in the afternoon so that the pipes, walls,drains and floors can be pressure washed and deep cleaned. The trashes,shelves, microwave counters and stove are cleaned daily, and will continue to follow the cleaning checklist. A staff member was hired to focus on maintaining the deep cleaning of these surfaces on a weekly basis. B. The doorways and thresholds will be repaired and painted after the pressure washing is complete. It is expected to be completed by 2/21/25. The window seal striping was purchased and will be replaced after the pressure washing and expected to be completed by 2/21/25. Light fixture panels were purchased and will be replaced by 2/21/25. Walk-in cooler will be defrosted and ice build-up will be removed on 2/16/25. A call was placed to Northwest Mechanical to request a quote to repair the leak that is causing build-up. Refrigeration fans were cleaned and will continue to be cleaned as a part of the monthly checklist. Dish machine was fixed and is functioning at the correct temperature and sanitizing levels. This was corrected 1/28/25. A cover was purchased to cover the gap and hole around the pipes. C. Dish machine was repaired by Ecolab and is functioning at the required temperature and dispensing amount. The test strips were replaced with new ones. The strips that were used for testing during the visit were for testing chlorine and were incorrect. This was corrected 1/28/25. D. The wall dispensing unit was inspected and serviced by Ecolab and is in proper working order. This was corrected 1/30/25. E. A thermometer is present in the meal preparation area and staff have been educated on the importance and requirement of testing food temperatures and utilizing the log. This was corrected 1/28/25. 4 additional thermometers were purchased. A clipboard and hooks were purchased to assist with keeping the logs organized and within reach. F. Dining staff were educated on the requirement to wash all produce prior to preparing the food. Staff were required to read and sign this information as proof of acknowledgment. This was corrected 1/28/25. G. Staff were reminded that hair restraints need to be used when cooking and handling clean dishes per rule. This was corrected 1/28/25. H. Plastic totes with locking lids were purchased to store the disposable silverware. Staff were educated on the proper way to secure silverware in order to prevent exposure to contamination. This was corrected 2/11/25. I. Staff were educated on the appropriate place to store dish racks when they are not in use. This was corrected 1/28/25 DSM will continue to monitor and oversee the daily.weekly and monthly cleaning to prevent this from happening in the future. The facility Maintenance Director will do monthly walkthroughs of the kitchen to inspect for any repairs, painting or items that may need replaced. Executive Director will meet weekly 1:1 with DSM to ensure that the Kitchen is in compliance with training and structure.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: