Print Inspection: KIT000219

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 a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 09/10/24 and 08/11/24 showed the following areas needed cleaning or repair. * Drips, splatters and/or debris were observed inside cupboards, under shelves, inside drawers, behind the ice machine and on the walls throughout the kitchen and dry storage; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the kitchen a black/brown haze. Multiple seams were cracked or pulling apart, large cracks were present between patched flooring areas, thick areas with missing caulking and missing pieces of flooring were noted in several areas of the kitchen; * Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and/or chipped/peeling/cracked shelf coating; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and/or bubbling paint. Open shelving and cupboards on both sides of the steam table had heavily stained or discolored shelves with clean dishes stored on them. Additional open shelving units under the drink station had dark stains, debris and chips/dings and exposed particle board; * Chipped laminate was noted on counter edges; * Baseboards were pulling away from the wall near the freezer/refrigerator units; * Three cutting boards were significantly worn, grooved and stained; * Two frying pans, one small and one large, and three pots, one small, one medium and one extra-large, had significant carbon build up with dented and/or pitted pot bottoms; * Caulking around the handwashing sink was discolored black/gray and cracked; * Debris was noted on top of the dish machine; * Ceiling vent near dry storage had significant thick dust buildup; * The wall on the “dirty” side of the dishwashing area had a long area of dark black discoloration along the grout line between the wall and metal back splash; * Dust buildup was noted on the vents to the ice machine; * Freezer unit was not operating properly at the time of survey. The temperature of the freezer was between 30 and 34 degrees. Frozen items had been removed and items requiring refrigeration were being stored in the unit. The unit had been broken for 2-3 days at the time of survey with multiple previous repairs noted per staff and a request for repair submitted for current issue; * Both ovens were not maintaining appropriate temperatures based on the selected temperature on the dial. Per staff the left side ran much higher than the temperature dial indicated, the right-side temperature ran low compared to the dial selection. Multiple staff indicated the right oven was primarily used for desserts to avoid any issues with undercooking; * Spills and debris noted to the shelves and on top of items in the dry storage area as well as debris underneath shelving units; The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Sister Facility ED), Staff 2 (Dietary Services Manager) and Staff 3 (Cook) on 09/10/24. The staff acknowledged the findings.

Repair or Replacement -kitchen floor 1. Will be repaired by Maintenance Manager with the assistance of the Regional Maintenance Manager and COO of Lenity. 2. ED, Patrick James will ensure all items needing repaired/replaced are addressed with Maintenance Manager 3. Maintenance Manager will inspect monthly with the Dining Service Manager to ensure kitchen floor repairs are done in a timely manner. 4. ED to monitor for completion during weekly 1:1 with the MM.

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 a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the kitchen on 02/04/25 showed the following areas needed cleaning or repair. * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the kitchen a black/brown haze. Multiple seams were cracked or pulling apart, large cracks were present between patched flooring areas, thick areas with missing caulking and missing pieces of flooring were noted in several areas of the kitchen; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and/or bubbling paint. * Baseboards were pulling away from the wall near the freezer/refrigerator units; * Caulking around the handwashing sink was removed, and discoloration was noted between the wall and back splash; * The wall on the “dirty” side of the dishwashing area had a long area of dark black discoloration along the grout line between the wall and metal back splash; * Both ovens were not maintaining appropriate temperatures based on the selected temperature on the dial. Per staff the left side ran much higher than the temperature dial indicated, the right-side temperature ran low compared to the dial selection. Staff 2 (Dietary Services Manager) indicated the right oven was no longer used; and * The entrance, exit, and dry storage room doors and door frames had worn pain with exposed door surfaces, black scuffs, and chips and gouges throughout. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 2 and Staff 4 (RN, Manager on Duty) on 02/04/25. They acknowledged the findings.

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 a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the kitchen on 06/18/25 showed the following areas needed cleaning or repair. * Sections of flooring in the dry storage and the back storage room had missing pieces, small gouges, cracks and uneven surfaces creating debris accumulation. The flooring in these areas had black and orange/brown discoloration and stains; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and/or bubbling paint. Cupboard shelves and sides of the units were discolored, stained and/or had spills and debris; * Both ovens were not maintaining appropriate temperatures based on the selected temperature on the dial. Per staff the left side ran much higher than the temperature dial indicated. Staff 2 (Dietary Services Director) indicated the right side of the oven would not maintain consistent heat and had begun to shoot small flames under the door. The right side of the oven was no longer used or kept on; and * Chipped countertop with missing laminate and gouged cupboard doors with exposed and untreated wood were noted in the back storage room. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 2 and Staff 5 (ED) on 06/18/25. They acknowledged the findings.

1. Flooring in the kitchen is being completed by maintenance manager. We have hired a new manager and the maintenance manager from Azalea is training him and they will have the floor completed before next revisit. 2.Cupboards and shelves are being painted and repaired by maintenance and will be completed before next revisit. 3. both ovens have been repaired and we have added an oven thermostate as well to assist in accurate temps. 4.Chipped countertop with missing laminate and gouged cupboard door are being repaired by maintenance manager and his replacement and will be completed before next revisit.

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 and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: 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: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

This is being repiared and fixed by maintenance director and his replacement and will be in compliance before next revisit

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:

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 observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240

1: A thorough, professional cleaning of the entire kitchen will be completed, All refrigerators, freezers, and dry storage areas will be thoroughly cleaned, including removal of spills, rust, and debris. 2: A revised cleaning schedule will be implemented, with daily, weekly, and monthly cleaning tasks assigned to the kitchen staff. 3. Weekly audits will be conducted by the Dietary Services Manager to ensure cleanliness and adherence to the new cleaning schedule. 4: ED and DSM will monitored and completed.

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 observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

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 observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

1. Flooring in the kitchen is being completed by maintenance manager. We have hired a new manager and the maintenance manager from Azalea is training him and they will have the floor completed before next revisit. 2.Cupboards and shelves are being painted and repaired by maintenance and will be completed before next revisit. 3. both ovens have been repaired and we have added an oven thermostate as well to assist in accurate temps. 4.Chipped countertop with missing laminate and gouged cupboard door are being repaired by maintenance manager and his replacement and will be completed before next revisit.

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: