Print Inspection: KIT001039

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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 10/31/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: *Fan, which was operating, on beverage counter pointed toward service line – heavy dust buildup; * Commercial can opener – build up of debris on blade; * Food storage bins – lids and exteriors buildup of food debris; * Hood vents above cooking equipment – dust/grease build up; * Hood above dishwasher – heavy buildup of black matter; * Refrigerator next to hand washing sink – bottom shelf buildup of spills/debris; * Wall below spray hose sink in dishwashing area – black/brown matter spills/drips; * Caulking above sink in dishwashing area – buildup of black matter; * Flooring and drains underneath counters and equipment throughout the kitchen – buildup of black matter/debris; and * Lower shelving throughout the kitchen – spills/debris/splatters. Improper food storage concerns included: * Rolling cart (next to door) in walk in refrigerator – four trays of uncovered/unlabeled desserts; * Rolling cart (back wall) in walk in refrigerator – one tray of uncovered/unlabeled meat portions; and * Butler pantry – one tray of uncovered/unlabeled desserts. The areas of concern were observed and discussed with Staff 1 (Food and Beverage Director) and discussed with Staff 2 (Administrator) on 10/31/24. The findings were acknowledged.

Kitchen staff meeting 11/14/24 to cover plan of correction and discuss systems in place to ensure safety and compliance. 1. Kitchen has a cleaning (daily, weekly and deep) schedule to include, but not limited to, fridges, hood vests, shelves, walls, dishwashing areas, floors and drains. Checklists will be reviewed by Culinary Director for completion to ensure all cleanliness standards are being met and maintained. *food storage bins (external) and lids to be cleaned daily * no open fans in kitchen that can blow dust/debris *comercial can opener to be cleaned after use to ensure no build up of residue 2. Rolling carts in fridge to be covered (full zip cart covers on order.) 3. Butler pantry desserts (or any other food in service area) to be covered prior to delivery 4. All items on plan will be monitored by Culinary Director (daily/weekly/monthly) and reviewed with the Executive Director at weekly 1:1s.

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:

1. Kitchen staff meeting will be held on 1/15/25 to cover plan of correction and discuss systems in place to ensure safety and compliance. All staff will sign off on the plan. 2. Kitchen has a detailed cleaning (daily, weekly and deep) schedule to include, but not limited to, fridges, hood vent, shelves, walls, dishwashing areas, floors and drains. Checklists will be reviewed by Culinary Director for completion to ensure all cleanliness standards are being met and maintained. *food storage bins (external) and lids to be cleaned daily * no open fans in kitchen that can blow dust/debris *comercial can opener to be cleaned after use to ensure no build up of residue Hood vent cleaning cheduled 1/8/25, with quartnerly maintence set up. Exterior cleaning by kitchen staff. *Rolling carts in fridge to be covered (full zip cart covers on order.) 3. All items on this plan will be monitored by Culinary Director (daily/weekly/monthly) and signed off. 4. Kitchen cleanliness will be assessed with walk-through with Executive Director, and completed checklists will be reviewed at weekly 1:1s.

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:

1.The community will maintain compliance to the plan of correction. 2. The Culinary Director will monitor compliance by reviewing cleaning checklist and performing visual inspections. 3. The Culinary Director will assess daily, weekly and monthly checklists. 4. The Culinary director will share progress with Executive Director at weekly 1:1's. The Executive Director will perform spot checks periodically to ensure all areas are in compiance.

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: