Inspection Details: KIT008072


Date
11/24/2025
Event ID
KIT008072
Inspection type(s)
Kitchen
Deficiencies cited
2

Citation Details

C0240
Severity Level: 2
Visits: 2
Scope
L2 Widespread
Visit Number
1
Visit Date
11/24/2025
Corrected Date
N/A
Details

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 in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-00. Findings include, but are not limited to: Observation of the main kitchen and the memory care kitchenette on 11/24/25 from 10:10 am through 2:30 pm revealed the following areas: 1. Main Kitchen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, white powdery matter and grease was visible on or underneath the following: * Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine; * Kitchen drains; * Trash cans, exterior; * Exterior of cabinets and drawers; * Walls throughout kitchen; * Stove/grill knobs, doors, exterior; * Burner top and interior of ovens; * Industrial Globe mixer; * Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges; *Rack shelving in reach in cooler (at end of hot line) covered in white billowy matter and black debris; * Dirty napkin on metro rack in dry storage; * Plate holder/warmer outside surfaces with food debris and dried food spills; * Containers on ground behind plate holder/warmer covered in dried food debris; * Shelving in ware washing area holding chemicals (Simple Green, etc.) covered in dried food debris; * Floor under ware washing chemical shelf heavily covered in grease, food spills and food debris; * Rubber seal on lid of chest freezer contained black debris in multiple areas; * Catch trays under range top burners and flattop griddle were covered in spilled and burnt food debris; * Black speckled debris on interior walls of ice machine; * Black debris build up in and around window frame in kitchen near oven; * Chair seats in dining room have spills and stains; * Floor under dining table dirty with food debris; * Bases of tables in dining room dirty with food debris; * Popcorn machine in dining room-walls of food containment area dirty with grease and food debris, “hopper” of machine has build up of grease; and * Floor between ice machine and wall. b. Observations of food being plated for service immediately adjacent to handwashing sink. Visible food debris found in hand washing sink. Main Hand washing sink did not have a splash guard to protect service/plating area from potential splash contamination or food debris contamination falling into sink from service. c. Multiple food packages in freezer and reach in coolers not properly closed/left open. Multiple food opened packages in reach in cooler not labeled or dated. d. Back door near ware washing area was observed left open without a screen to prevent potential entry of pests/insects. e. Kitchen staff observed handling/preparing/serving food without proper facial hair restraints/coverings. f. Container of Recycling (bottles and cans) observed being stored in dry food storage area. Container was noted to be overflowing, not covered and not with appropriate liner. g. Improper use of food handling gloves observed. Kitchen staff wearing gloves and touching multiple un-sanitized and potential contaminated items/surfaces before then handling ready to eat foods. h. Multiple kitchen staff members who were observed preparing/serving food and/or handling clean dishes, were not observed wearing facial hair restraints. i. Rack shelving in dry good storage covered in carboard used for shelf lining which was not a smooth/cleanable surface. A dirty/used napkin was noted on the shelf where food was stored. j. Multiple packages or containers storing food in dry storage was noted open and not protected from potential contamination. 2. Memory Care kitchenette a. * An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or white powdery matter and grease was visible on or underneath the following: * Microwave contained food debris; and * Floor between wall and refrigerator dirty. b. Care staff observed delivering food trays/plates to residents and rooms without wearing an apron. Care staff was observed to take entire food delivery cart (with multiple residents’ food on cart) into resident’s room potentially contaminating service cart and other resident’s meal items. c. Dirty dishes and flat wear observed in dedicated handwashing sink. d. Open containers of soda pop and energy drinks (belonging to employees) observed stored with resident food/beverages in the resident fridge. e. Reach in refrigerator storing resident food and beverage items were found to hold a Ranch squeeze bottle with a date marked “7.16” and an (unlabeled) squeeze bottled containing what looked like vinaigrette dressing with a date marked “7.21.” Both items were found well past the seven days allowed per rule and without manufactured recommended discard dates. Staff 2 acknowledged those items were salad dressings and that they were well past their use by dates and should have been discarded. f. No initial handwashing was observed by care staff prior to serving/delivering food to residents. g. The space immediately next to resident fridge (between fridge and wall) was being used as a makeshift mop/broom closet. Dirty mophead and grime observed on floor in this area directly adjacent to resident cold food storage. On 11/24/25 at approximately 2:30 pm Staff 2 (Dining Manager) was interviewed and the above areas were reviewed. Staff 2 acknowledged the areas needing correction. At approximately 2:45 pm Surveyors reviewed findings with Staff 1 (Administrator), who acknowledged the findings.

Plan of Correction

1. The identified areas of the SOD conducted on 11/24/2025 will be addressed and corrected through regular cleaning, deep cleaned, repair and replacement of defective equipment. 2. Dietary staff will be retrained on the following but not limited to topics: a. Food safety b. Food storage guidelines c. Kitchen sanitary guidelines d. Caring Places Management kitchen expectations Checklists will be created to ensure that we are back in compliance. 3. Dietary manager will review with kitchen team weekly. Dining Manger and Administrator will meet monthly to ensure compliance with OARs. 4. Dietary Manager and Administrator

Visit Number
2
Visit Date
1/26/2026
Corrected Date
N/A
Details

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:

Z0142
Severity Level: 2
Visits: 2
Scope
L2 Widespread
Visit Number
1
Visit Date
11/24/2025
Corrected Date
N/A
Details

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Plan of Correction

See tag C240

Visit Number
2
Visit Date
1/26/2026
Corrected Date
N/A
Details

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: