Print Inspection: KIT001087

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, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: 1. Observations of the facility main kitchen, food storage areas, food preparation, and food service on 11/04/24 revealed: * Splatters, spills, and drips noted on: - Food storage bins under the tray-line; - Shelving throughout the kitchen; - Exterior of the range; - Interior of the microwave; - The stand mixer; - The free standing air conditioner; - Walls and equipment in the dishwashing area including the vent above the dish machine; * Black matter noted on the can opener blade; * Dust and debris was built up on metal storage shelves throughout the kitchen; * Dust and debris noted on cage of rotating fans blowing onto the food preparation area; * Multiple bottles and jars of foods noted to require refrigeration were left in an un-refrigerated food storage area; * Undated food items and food items with dates older than seven days were noted in the reach in refrigerator; * Packaged foods were not dated when opened; * Raw eggs were stored above leafy greens; * Boxes were stored on the floor in the walk in refrigerator; * The cove-base and flooring was broken, cracked, and damaged with an accumulation of debris; and * The screen on the back entrance to the kitchen was damaged allowing the entrance of flies and pests. The commercial high temperature dish machine was observed in operation multiple times. It was not reaching the specified temperature required for the sanitizing rinse cycle. There was no evidence of consistently monitoring the temperatures of cooked foods, refrigerator temperatures, and the dish machine temperatures. The kitchen was toured with Staff 2 (Dietary Manager) and Staff 4 (Maintenance Director). Staff 2 reported dishes would be washed and sanitized in the triple pot sink area until the dish machine was operating correctly. 2. Observations of the facility Memory Care kitchens, food storage areas, food preparation, and food service on 11/04/24 revealed: * Splatters, spills, and drips noted: - Inside drawers, cupboards, and on shelving; and - Interior of the reach refrigerators and freezers including in the door seals. A plate of food was left in the microwave of Country House. The front of the lower drawer to the left of the sink was broken off in Tuscan House. The dish sanitizers in both Tuscan and Country Houses were not operating per specifications. There was no detergent, rinse aid, or sanitizer in use, the hosing for each chemical was left lying under the kitchen sinks. Staff 2 reported dishes would be washed and sanitized in the triple pot sink area until the dish machine was operating correctly. The safe food handling and storage concerns areas in need of cleaning and repair were reviewed with Staff 2 and Staff 4. They acknowledged the findings.

MC Kitchen Immediate Actions: All of the Splatters, spills, drips were cleaned the day of the inspection. Staff was educated regarding the food left in the microwave and the food was removed and disposed of. The front drawer that was off in the Tuscan house was repaired. Washing and sanitizing dishes has been changed to the 3 sink method until equipment can be repaired or replaced in all homes. Near future Actions: The sanitizers will be replaced System Correction: On going cleaning daily cleaning task list to be completed by kitchen staff will be reviewed for any correction or additions relating to the findings. These tasks will be completed before the end of the day every day. Weekly deep cleaning of all areas will be added in addition to the daily task list and assigned to specific persons to allow follow up and accountability. The night shift task list will be reviewed and updated and additional education on food safety will be developed and scheduled. Monthly Continued training will be developed and assigned to kitchen staff on a rotating schedule regarding cleaning, food safety, temperature monitoring and documenting, etc. Audit/Follow up/Responsible Party: The dietary manager will inspect all areas 5 days a week Monday - Friday for compliance. The administrator will do a bi weekly (every 2 week) audit of all areas. The disiplinary policies will be followed to ensure accountability.

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 03/13/25 showed the following areas needed cleaning or repair. * Flooring throughout the kitchen had large black/gray stains, gouges, severe cracked edges and corners, corners were pulled away from the edges of the walls in several areas, chunks of the top layer of linoleum were missing and seams were pulling apart which created gaps in the floor. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dietary Manager) on 03/13/25. The staff acknowledged the findings.

Replacement of the commercial kitchen flooring: A quote, product selection and replacement will take place as soon as it can be scheduled. All attempts will be made to meet the deadline given by CBC.

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: Observation of the kitchen on 06/04/25 showed the following areas needed cleaning or repair: The floor throughout the kitchen had large black/gray stains, gouges, and severe cracked edges and corners. The corners were pulled away from the edges or the walls in several areas, chunks of the top layer of linoleum were missing, and seams were pulling apart which created gaps in the floor. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dietary Manager) on 06/04/25. The staff acknowledged the findings.

Replacement of the commercial kitchen flooring: We have received the quote and have the product waiting. Replacement will take place as soon as it can be scheduled. All attempts will be made to meet the deadline given by CBC.

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 their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

See 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:

see C 240

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. Findings include, but are not limited to: Refer to C 240.

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, 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

See 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:

see C 240

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: