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, and interview, it was determined the facility failed to maintain the kitchen and serve food in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen reviewed on 07/16/25 from 11:00 am through 1:15 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter and grease was visible on or underneath the following: * Interior of reach in freezer * Interior of deli cooler * Floors of walk-in cooler (threshold) * Floors of walk-in freezer (main and under shelving) * Interior of ovens, * Fan cages, blades and ceiling in walk in-cooler * Industrial can opener and housing * Interior of ice machine * Stainless steel shelving * Drain under steam table * Interior of popcorn machine kettle b. The following areas needed repair: * Section of flooring in ware washing area cracked/gaps c. Multiple staff preparing food or handling clean equipment observed without hair or facial hair restrained as required. d. Staff member observed to enter kitchen and into walk in cooler and removed containers of ice cream. This staff did not wash hands and did not restrain hair before handling food/equipment. e. Multiple staff were observed to contaminated gloves by touching meal tickets, opening oven, putting gloves in oven mitts, touching microwave handle, deli cooler handle, oven knobs then touch ready to eat food items (hot dog bun, orange slices, rolls/garlic bread). A care staff member was observed multiple times to touch plated food with their hands prior to putting cover over food. These practices potentially contaminated ready to eat foods served to residents. f. Kitchen staff member heated up multiple cans of soup in the microwave and did not stir the food product after cooking nor check the temperature of the food product prior to service to residents to ensure they were at palatable temperatures or hot holding temperatures (135 degrees or hotter). g. Kitchen staff member was observed to put in a hot dog to cook in microwave for 1 minute. Hot dog was removed from the microwave immediately after cook time and was placed up for service without checking the temperature to ensure at appropriate safe or palatable levels. Surveyor intervened and requested temperature checked. Hot dog was at 154 degrees. Staff was asked what temperature it should be, and they indicated 165. Staff put the hot dog back in the microwave and cooked to 170 degrees. Staff were not heating food in microwave according to approved methods. h. Facility was using a Lemon Quat disinfectant for surface sanitation. Direction for product included a need for 10-minute contact time with a water rinse after. Product was not for use on Food contact surfaces. There were no strips for product to validate/determine effective parts per million required for disinfection. Staff were observed to wipe a thermometer with a rag saturated with the solution. Staff 2 (Kitchen Manager) was not aware the chemical was not for food contact surfaces and did not know the contact time required and the need for a water rinse/removal after application. At approximately 12:30 pm surveyor reviewed areas with staff 2 who acknowledged the identified areas. At 1:00 pm, surveyor discussed areas in need of correction with Staff 1 (Executive Director) who acknowledged areas of concern.

A. Kitchen Manager did a deep clean of the Kitchen; food spill, splatters, loose food, trash dibri, dust, black matter, grease all removed during deep clean. Kitchen Manager deep cleaned interior of reach in freezer, interior of deli cooler, floors of walk-in cooler, floors of walk-in freezer, interior of ovens, fan cages, blades and ceiling in walk-in cooler, industrial can opener and housing, interior of ice machine, stainless steel shelving, drain uder steam table. Executive Director had an all staff kitchen meeting and discussed with new and old staff the importance of sanitation. Cleaning logs will be followed daily, weekly, and monthly. Kitchen manager will f/u up weeking with all cleaning logs and report to executive director if staff is not following cleaning tasks. B. Executive director notified Kauffmans Home Mt and scheduled on 7/24/25 for flooring area in wash area of kitchen. Kauffmans will be repairing on 8/29/25. Maintenance will inspect kitchen monthly for ware and tare areas and report to executive director. C. Executive director completed all kitchen staff training on 7/24/25 regarding preparing or handling equipment with hair nets/facial covering. Kitchen manager will report to executive director if staff is not following hair restaint requirement. Executive director will complete documentation with staff and if violation continues can lead to termination. D. 7/24/25 excutive director completed training with all staff including activity director regarding only kitchen staff is allowed in kitchen. If staff need an item out of the kitchen, kitchen staff can get the item for them. Executive director and Kitchen Manager will monitor. Kitchen staff put signs outside kitchen door. E. Executive director completed all kitchen staff training/meeting on 7/24/25 and went over how gloves are used in the kitchen. Kitchen staff received hand out. Kitchen manager will monitor daily and report anyone not following proper glove handling to executive diretor. F. Executive director completed training/meeting on 7/24/25 with all kitchen staff. Went over proper food temps, and when temps are requried. Executive director gave a hand out to all kitchen staff. Kitchen manager will monitor and ensure all kitchen staff are temping food properly. Any staff that fails to follow temperature of food, kitchen manager will report to executive director. G. Executive director completed training/meeting on 7/24/25 with all kitchen staff. Discussed with all kitchen staff all food that is being heated up in microwave must have temperature taken before plate can be served. Executive director gave a hand out to all kitchen staff. Kitchen manager will monitor and ensure all kitchen staff are temping food properly when using the microwave. Any staff that fails to follow temperature of food when using microwave, kitchen manager will report to executive director. H. Executive director called chemical vendor (Waxie) on 7/29/25 to schedule a training with all kitchen staff. Waxie came out on 7/30/25 and completed a training with all kitchen staff regarding proper food cleaning sanitation processs. Waxied brought test strips and demonstrated with all kitchen staff. Kitchen manager will monitor all kitchen staff and continue to train new staff. Kitchen manager will report to executive director if an issues with kitchen staff not following sanitation process.

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 and serve food in a sanitary manner and failed to ensure potentially hazardous food items had a temperature of 41 degrees Fahrenheit or less when removed from a cold holding environment, in accordance with Food Sanitation Rules, OAR 333-150-000. The facility’s walk-in cooler was recorded to have temperatures greater than 41 degrees Fahrenheit for multiple days, during which time the facility continued to utilize items from the cooler for food service, putting residents at risk of food-borne illness. This is a repeat citation. Findings include, but are not limited to: The kitchen was observed on 10/02/25 between 11:45 am and 3:20 pm, staff were interviewed, and food temperature logs were reviewed. The following was identified: a. At 12:21 pm on 10/02/25 the thermometer for the facility’s walk-in cooler read 45 degrees Fahrenheit. Temperature logs for 09/01/25 through 10/02/25 showed that staff documented the walk-in cooler temperature as being greater than 41 degrees Fahrenheit, up to 45 degrees Fahrenheit, every day between 09/28/25 and 10/02/25. Staff 3 (Cook) stated that he was responsible for documenting the temperature after lunch service, and that Staff 2 (Kitchen Manager) documented the temperature in the morning prior to breakfast service at approximately 6:00 am. Staff 3 stated that the temperature had been “reading high for a few days” and that he would be concerned if the temperature was higher than the “30’s” but stated he had not shared the information with anyone. Staff 2 stated that if employees noted a temperature greater than 40 degrees Fahrenheit the expectation was that she would be called, and she acknowledged that had not been occurring. She stated that she had noticed the walk-in cooler temperature was higher than 41 degrees Fahrenheit and had called a repair service but did not have a confirmed date or time of when they would be arriving to fix the cooler. She stated she had not checked any food temperatures of the items in the walk-in cooler during the past five days and had continued to use the potentially hazardous food items in food service for the residents. Staff 2 was unable to state what she would do in the case of identifying food items that were not cooled at a safe temperature and stated she would ask Staff 1 (Executive Director). Staff 2 checked the temperature of items in the walk-in cooler at 12:33 pm. An individually packaged yogurt was measured at 51 degrees Fahrenheit, and deli ham was measured at 50 degrees Fahrenheit. Staff 2 acknowledged that the food temperature was not currently less than 41 degrees Fahrenheit and did not know how long the food had been greater than 41 degrees Fahrenheit. The potentially hazardous food had been kept outside of safe temperature for an unknown period of time and needed to be thrown away. However, at 12:35 pm, Staff 1 and Staff 2 moved the potentially hazardous food items to their reach-in cooler instead of properly disposing of the items. The surveyor asked Staff 1 and Staff 2 to dispose of the potentially hazardous items. An immediate plan of correction was requested on 10/02/25 at 1:50 pm. The facility provided a plan of correction on 10/02/25 at 2:42 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. b. An accumulation of food spills, splatters, loose food, trash debris, dirt, dust, black matter, and/or grease was visible on or underneath the following: * Interior of reach-in cooler near serving station; * Floors of walk-in cooler (main and under shelving); * Floors of walk-in freezer (main and under shelving); * Interior of ovens; * Ceiling of walk-in cooler; and * Stainless steel shelving in dry storage area. c. A staff member preparing and serving food was observed without facial hair restrained as required. d. Multiple staff were observed to contaminate gloves by touching meal tickets, microwave handle, and/or deli cooler handle and then touching ready-to-eat food items and prepared food items. e. The facility’s bucket for surface sanitation measured at zero parts per million (ppm) and kitchen staff were unable to verbalize the correct frequency for changing the solution. The disinfectant used for the solution had instructions which stated that when used on items which could come into contact with food, such as a temperature probe, the items would need to be rinsed with potable water. Staff 2 was not aware of these instructions for use and stated that kitchen staff used the sanitizing solution to clean temperature probes when checking food temperatures during meal service. The need to ensure the kitchen was maintained and food was stored and served in accordance with the Food Sanitation Rules was reviewed with Staff 1 on 10/02/25 at 3:30 pm. She acknowledged the findings.

A. Executive Director elvaluated overall kitchen training and implementation of systems. 1. Kitchen staff completed Oregon Care Partners on-line education, "Keeping Food Safe and Nourshing For Older Aults". All new staff when hired will complete on-line training. 2. All kitchen staff will complete on-line kitchen Infection Control for Healthcare Food Service Part I & Part II. Executive director reviewed with all kitchen staff CBC Annual Kitchen Inspection. Staff will review with excutive director annually and when new staff is hired. Executive director provided direct training with all kitchen staff cross contamination with raw and cooked food, proper use of wearing gloves, and cheking sanitizer ppm/when to change, & checking refrigeration temps. All systems will be reviewed annually by executive director. Kitchen Manager will observe and oversee day to day tasks are completed by kitchen staff. Kitchen manager will report to executive director. B. Kitchen manager completed a deep clean of accumulated food spills, splatters, loose food, trash debris, dirt, dust, black matter, and /or grease in the kitchen reach-in cooler, floors of walk-in cooler, walk-in freezer, interior ovens, ceiling of walk in cooler, and stainless steel shelving in dry storage area. Kitchen staff completed on-line food safety and sanitation training. Kitchen staff will complete annually. Kitchen manager will observe and oversee day to day cleaining schedules ensuring tasks are complete thoroughly. Kitche manager will report to executive director. C. Staff completed on-line Food Safety course and any further incidents will lead to termination for not following policy. Kitchen manager will report to executive director if policy is not being followed. Executive director did a hands on training with all kitchen staff how to use a beard net and hair net. D. Executive director completed a hands on training with all kitchen staff on when to wear gloves and contamination. All kitchen staff completed on-line training kitchen infection control for healthcare food service part I and part II. All kitchen staff completed on-line training Keeping Food Safe and Noursishing for Older Adults. Executive director will observe kitchen staff serving meals monthly and kitchen manager will observe kitchen staff during daily shifts. Staff that is not following kitchen sanitation and food safety will be reported to executive director and further training or possible terminiation will be addressed. E. All kitchen staff completed on-line traing Cleaning & Sanitizing Food Surfaces video. Executive director had all kitchen staff demonstrate Cleaning and Sanitizing - hands on training completed. Kitchen manager demonstrated task of Cleaning and Sanitizing, checking ppm, and when to change sanitizer (bucket solution). Annual training will be completed by executive director with the assistance of the kitchen manager. Kitchen manager will observe daily during shifts that proper sanitation is being followed. Executive director provided cleaning and sanitizer wipes for all food temperature probes. Kitchen manager will report to executive director.

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:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure the plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C240.

Refer to C240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: