Print Inspection: KIT001987

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: C150 Based on the findings of the first re-visit to the kitchen inspection of 11/07/25, conducted 01/12/26, indicate administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on the scope of the C240 citation. Based on observation and interview it was determined the licensee failed to ensure adequate administrative oversight of facility operations for food services. Findings include, but are not limited to: During the first revisit of the kitchen inspection of 11/07/25, conducted 01/12/26, administrative oversight to ensure adequate food services rendered in the facility was found to be ineffective based on failure to implement plan of correction and ensure adequate oversight to correct deficiencies. Refer to C 240.

See C240. ED involved with the training and oversite of the POC.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

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 in a clean and sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen, food service, food storage areas, and the activities kitchen area occurred on 11/4/24 from 10:50 am through 1:30 pm and revealed the following: 1. Main Kitchen: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Handwashing sink faucet area; * Top of commercial dishwasher; * Dishwashing sprayer handle; * Pipes, walls, gauges, disposal, drain, walls, and flooring behind/underneath the dish machine; * Black utility cart; * Removable hood vents above stove/grill; * Floors under and behind range and ovens; * Exterior of range/cook top; * Interior of right oven; * Edges near knobs for steam table; * Bottom of plate warmer; * Interior of microwave oven; * Spice shelves; * Kitchen drains under steam table; * Top shelf of steam table above line; * Industrial and countertop mixers; * Metal table holding industrial mixer; * Metal rungs of movable baking rack; * Large can opener and housing; and * Juice machine on and near the nozzles; b. The following areas needed repair: * Missing cover around sprinkler head yielding large open area; and * Large section of plastic wall corner piece damaged and pulled away from wall;. c. Test strips for dish machine were not available to staff to accurately test chemical concentration of dish machine. Staff were monitoring the temperatures of the rinse but not the chemical concentration. The dish machine used chlorine for sanitation, and the kitchen had quaternary ammonia strips. Staff 2 (Dining Service Manager) was unaware the sanitation levels of the dish machine needed to be monitored. d. Multiple items in the walk-in refrigerator were not dated or labeled when opened or prepared. Multiple food items were found past the seven days from opening or preparation and should have been discarded. e. Kitchen staff was observed to handle ready-to-eat items with potentially contaminated gloves while making sandwiches and/or burgers. This staff was observed to handle utensils, touch handles of walk-in cooler, and other potentially contaminated items with their gloves and then touch ready-to-eat items. This staff was observed to not change their gloves or wash their hands when needed. 2. At approximately 12:30 pm through 1:30 pm, the activities kitchen space was observed, and the following was identified: a. The reach-in refrigerator and freezer was observed to have an accumulation of food spills, dirt, dust debris, hair, and other potential contaminates. Resident food and beverage items were stored in the refrigerator/freezer for activities purposes. The microwave, popcorn machine, and toaster oven were observed with dried-on loose food debris, spills, and splatters and in need of cleaning. Reach-in cabinets and drawers were observed storing food and cooking supplies that had visible dried-on loose food debris, spills, and splatters. b. Dishes were observed in a dish drying rack. Staff 3 (Activities personal) was interviewed and verified there was no sanitation step involved when dishes were washed in the activities area. Staff 3 was unaware of the need to sanitize dishes used for residents. During the survey process the above areas were reviewed with Staff 2, who acknowledged the findings. At approximately 1:30 pm, the above areas were reviewed with Staff 1 (Executive Director), who acknowledged the deficiencies.

1. Areas in need of cleaning will be in compliance as of 12/20/2025. Needed repairs will be completed prior to 12/31/25. Chlorine test strips for the dishwasher are in use as of 11/14/25. 2. Checklists will be completed to ensure that cleaning is completed on a routine basis. Needed repairs will be communicated in stand up meeting to ensure proper follow up has occurred. Kitchen staff will be re-trained on the proper use of gloves and handwashing, as well as proper labeling, dating and shelf life of food items by 12/20/25. All food preparation activities will be completed in the kitchen prior to serving during activities and dishes will be returned to the kitchen for proper washing and sanitization. 3. These areas will be re-evaluated daily through review of daily cleaning checklists to ensure proper compliance with food sanitaion rules. 4. The Dining Services Manager will be responsible for implementation and completion of all needed corrections with oversight from the 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: Prestige Senior Living Southern Hills Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair 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, food service, food storage areas, and the activities kitchen area occurred on 01/12/26 from 10:30 am through 12:40 pm and revealed the following: 1. Main Kitchen: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Handwashing sink faucet area; * Dishwashing sprayer handle; * Pipes, walls, gauges, disposal, drain, walls, and flooring behind/underneath the dish machine; * Black utility cart; * Edges near knobs for steam table; * Spice shelves; * Industrial and countertop mixers; * Metal table holding industrial mixer; and * Juice machine on and near the nozzles; b. The following areas needed repair: * Missing cover around sprinkler head yielding large open area; and *Grate over drain for juice dispensing machine. c. Staff 2 (Dining Services Manager) was unable to adequately state parts the per million range required for effective warewashing sanitizer solution concentration. d. Multiple items in the walk-in refrigerator were not dated or labeled when opened or prepared. e. Surveyor asked Staff 2 to check sanitizer concentration of warewashing machine; there was no sanitizer in warewashing machine sanitizer cycle. The container of sanitizer solution itself had run out and there was not a replacement container of sanitizer. f. Surveyor observed standing water under the “booster” area of the warewashing machine along with a towel to collect/capture water. g. Surveyor observed a four-quart storage container under the warewashing sink disposal that contained stagnant water. h. Multiple warewashing machine racks were observed to be stored directly on the floor of the dry storage area. 2. Activities kitchen space: a. The microwave, popcorn machine, and coffee maker were observed with dried-on loose food debris, spills, and splatters and in need of cleaning. Drawers were observed storing clean towels and cooking supplies that had visible dried-on loose food debris, spills, and splatters in or around the bottom of the drawer. Multiple cooking utensils were found with dried-on food, food debris and grease. b. Cooked on food debris on bottom interior of oven and multiple serving dishes with food debris and dried food particles being stored in oven. During the survey process the above areas were reviewed with Staff 2 at 12:10pm who acknowledged the findings. At approximately 12:20 pm on 01/12/26 the above areas were reviewed with Staff 1 (ED), who acknowledged the findings. Prestige Senior Living Southern Hills C150 Based on the findings of the first re-visit to the kitchen inspection of 11/07/25, conducted 01/12/26, indicate administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on the scope of the C240 citation. Based on observation and interview it was determined the licensee failed to ensure adequate administrative oversight of facility operations for food services. Findings include, but are not limited to: During the first revisit of the kitchen inspection of 11/07/25, conducted 01/12/26, administrative oversight to ensure adequate food services rendered in the facility was found to be ineffective based on failure to implement plan of correction and ensure adequate oversight to correct deficiencies. Refer to C 240. C 455 Based on observation and interview it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

1. Deep clean was completed on 1/13/2026- This included walls, floors, drains, utility cart, shelves, mixers and juice machine. Repairs made- Replaced missing cover around sprinkler head and grate on juice machine. Training was completed on how and when to report maintenance issues to the POD/ED. Training was provided to kitchen staff on when and what things need to be dated in the kitchen. Dishwasher chemical check added to task sheet. New rack holder was ordered and extra non used racks removed for kitchen. 2. New cleaning schedule/task list was created for the kitchen and act. room. Training was provided on how to use the cleaning schedule. 3. Weekly 4. POD, ED and DSD

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: C 455 Based on observation and interview it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

1. New POC has been developed. POC has been reviewed with Kitchen staff, DSD, POD. 2. Continued education on POC and audits 3. Weekly 4. POD, ED and DSD

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: